Every finding on record at The Willows At Okemos

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment affecting 67 residents who consume food, resulting in the increased likelihood for cross-contamination and bacterial harborage.Findings include:On 04/14/2026 at 8:52 A.M., An initial tour of the food service was conducted with Director of Food Services (DFS) M. The following items were noted:Dry Storage Room: The return air exhaust ventilation grill was observed heavily soiled with accumulated and encrusted dust/dirt deposits. (DFS) M indicated he would have maintenance thoroughly clean the soiled ventilation grill as soon as possible.The 2022 FDA Model Food Code section 6-501.14 states: (A) Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials. (B) If vented to the outside, ventilation systems may not create a public health HAZARD or nuisance or unLAWful discharge.Food splash residue was observed on the overhead light assembly and ceiling surfaces, adjacent to the equipment storage rack. (DFS) M indicated he would have maintenance staff thoroughly clean and sanitize the soiled light assembly and ceiling surfaces as soon as possible.The 2022 FDA Model Food Code section 6-501.12 states: (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. (B) Except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods when the least amount of FOOD is exposed such as after closing.The Pitco fryer interior and exterior surfaces were observed with accumulated and encrusted food residue. (DFS) M indicated he would have dietary staff thoroughly clean and sanitize the fryer interior and exterior surfaces as soon as possible.The South Bend convection oven interior and exterior surfaces were observed with accumulated ad encrusted food residue. (DFS) M indicated he would have dietary staff thoroughly clean and sanitize the convection oven interior and exterior surfaces as soon as possible.The South Bend stove top and oven interior and exterior surfaces were observed with accumulated and encrusted food residue. (DFS) M indicated he would have dietary staff thoroughly clean and sanitize the stove top and oven interior and exterior surfaces as soon as possible.The South Bend char broiler exterior surfaces were observed with accumulated and encrusted food residue. (DFS) M indicated he would have dietary staff thoroughly clean and sanitize char broiler exterior surfaces as soon as possible.The Cleveland steamer stainless steel support table was observed with accumulated and encrusted food residue. (DFS) M indicated he would have dietary staff thoroughly clean and sanitize the steamer support table as soon as possible.The Manitowac ice machine interior white resin retention plate was observed with brown to black psychrophilic bacterial growth extending along the lower retention plate ridge. The bacterial growth measured approximately 1-inch-wide by 30-inches-long. (DFS) M indicated he would have dietary staff thoroughly clean and sanitize the ice machine basin as soon as possible.The Juice Machine under splash and drip tray assembly were observed with accumulated and encrusted food residue. (DFS) M indicated he would have dietary staff thoroughly clean and sanitize the Juice Machine under splash and drip tray assembly as soon as possible.The 2022 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.On 04/14/2026 at 3:06 P.M., A comprehensive tour of the food service was conducted with Director of Food Services (DFS) M. The following item was noted:On 04/14/2026 at 3:21 P.M., The mechanical dish machine wash temperature (130 degrees Fahrenheit) and final rinse temperature (168 degrees Fahrenheit) were observed out-of-range. The pounds-per-square inch (PSI) was also observed in range (23 PSI) during the final rinse session. (DFS) M stated: I will contact our service provider for repairs.The 2022 FDA Model Food Code section 4-501.110 states: (A) The temperature of the wash solution in spray type warewashers that use hot water to SANITIZE may not be less than: (1) For a stationary rack, single temperature machine, 74oC (165oF); (2) For a stationary rack, dual temperature machine, 66oC (150oF); (3) For a single tank, conveyor, dual temperature machine, 71oC (160oF); or (4) For a multitank, conveyor, multitemperature machine, 66oC (150oF). (B) The temperature of the wash solution in spray-type warewashers that use chemicals to SANITIZE may not be less than 49oC (120oF).The 2022 FDA Model Food Code section 4-501.112 states: (A) Except as specified in (B) of this section, in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90oC (194oF), or less than: (1) For a stationary rack, single temperature machine, 74oC (165oF); or (2) For all other machines, 82oC (180oF). (B) The maximum temperature specified under (A) of this section, does not apply to the high pressure and temperature systems with wand-type, hand-held, spraying devices used for the in-place cleaning and SANITIZING of EQUIPMENT such as meat saws.On 04/16/2026 at 5:00 P.M., Record review of the Policy/Procedure entitled: Dishmachine Guideline dated 4/25/13 revealed under Guideline: Dishmachines will be properly used to ensure cleaning and sanitation of dishes and utensils. Record review of the Policy/Procedure entitled: Dishmachine Guideline dated 4/25/13 further revealed under Procedure: (3) Start Up: (7) Check that temperatures are appropriate: High Temp-Wash temp should be 150 - 160 degrees Fahrenheit; Rinse temp should be 180-185 degrees Fahrenheit. Low Temp using Sanitizer - Temperatures should be between 120-150 degrees Fahrenheit. The optimal temperature for plastic ware is 140 degrees Fahrenheit. Test strips must be utilized for a low temp machine. (9) Low or abnormal temperatures will be reported to the Dining Services Manager or Manager in Charge.On 04/16/2026 at 5:15 P.M., Record review of the Policy/Procedure entitled: Dishmachine Temp/Sanitizer Guideline dated 4/25/13 revealed under Guideline: Dishmachine temperatures and sanitizer concentration will be accurately recorded to ensure proper sanitation of dishes and utensils. Record review of the Policy/Procedure entitled: Dishmachine Temp/Sanitizer Guideline dated 4/25/13 further revealed under Procedure: (1) The Dining Services Manager will post a monthly dishmachine temperature and sanitzer concentration log. (4) The Dining Services Manager will promptly address and correct any dishmachine problems to ensure proper sanitation of dishes and utensils.On 04/16/2026 at 5:30 P.M., Record review of the Policy/Procedure entitled: Grill dated (no date) revealed under Procedures: (1) Use a small amount of water (not cold) with the grill brick. (2) Scrub grill with grill brick scraping excess into drain. (3) Rinse surface clean. (4) Before next use, season the grill with a small amount of cooking oil.On 04/16//2026 at 5:45 P.M., Record review of the Policy/Procedure entitled: Oven dated (no date) revealed under Products: (3) Clean weekly of as needed. (10) Use stainless steel cleaner on the outside surfaces of the oven. (11) When glass is cool on door, clean exterior with glass cleaner.On 04/16/2026 at 06:00 P.M., Record review of the Policy/Procedure entitled: Ice Machine dated (no date) revealed under Procedures: (1) Remove ice from machine. (2) Apply descaler to surfaces. (3) Allow to work for 5-10 minutes. (4) Rinse clean with cool to warm water. (5) Sanitize inside surfaces and allow to air dry. (5) Refill with ice. (6) If desired, apply stainless steel polish to outside of ice machine.

Based on interview and record review the facility failed to complete a comprehensive assessment timely for three Residents (#12, #58, #68) of seventeen residents reviewed for comprehensive assessments.Findings Included: R12: Review of the medical record reflected R12 admitted to the facility on [DATE], with diagnoses that included Alzheimer's and chronic obstructive pulmonary disease (COPD). The Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/4/26, reflected R12 scored four out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 04/15/2026 at 4:39 PM, R12 was observed seated in his wheelchair, in the dining room. As of 4/16/26, the status of R12's Annual MDS, with an ARD of 3/4/26, was Finalized. Section V (Care Area Assessment (CAA) Summary) of the MDS was signed on 4/16/26. In an interview on 04/16/2026 at 9:40 AM, MDS Nurse K stated Section Z of R12's Annual MDS was signed timely. According to MDS Nurse K, work was done on the CAAs on 3/18/26, but they were never completed, so the MDS was not transmitted. According to the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2025, .required comprehensive assessments include the completion of both the MDS and the CAA process, as well as care planning. Comprehensive assessments are completed .annually .Assessment Management Requirements and Tips for Annual Assessments .The MDS completion date (item Z0500B) must be no later than 14 days after the ARD (ARD + 14 calendar days). This date may be earlier than or the same as the CAA(s) completion date, but not later than . The CAA(s) completion date (item V0200B2) must be no later than 14 days after the ARD (ARD + 14 calendar days). This date may be the same as the MDS completion date, but not earlier than . Resident #68 (R68) Review of the medical record demonstrated that R68 was admitted to the facility 02/25/2022 with diagnoses that included insomnia, left above the knee amputation, chronic kidney disease, severe protein malnutrition, type 2 diabetes, hypothyroidism (low thyroid hormone), hyperlipidemia (high fat levels in blood), urinary retention, anemia (low red blood cell count), peripheral vascular disease (PVD), gastro-esophageal reflux, and dementia. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/29/2026, revealed that R68 had Brief Interview for Mental Status (BIMS) of 13 (cognitively intact) out of 15. Review of R68's Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/29/2026, revealed that section V-Care Area Assessment (CAA) Summary was not completed signed by a Registered Nurse Coordinator for CAA Process and Date Signed was 02/20/2026. During an interview on 04/16/2026 at 09:40 a.m. Minimum Data Set (MDS) Nurse explained that she was a float MDS Nurse K for the company that had ownership of the facility. MDS Nurse K explained that she had been assisting the facility because the facility MDS Coordinator was on leave. MDS Nuse K confirmed that R68's MDS, with an Assessment Reference Date (ARD of 01/29/2026, section V-Care Area Assessment (CAA) summary was not completed signed by a Registered Nurse Coordinator for CAA Process and Date signed was 02/20/2026. MDS Nurse K explained that documented signature date of 02/20/2026 indicated that the MDS was completed late. Review of the clinical record revealed Resident #58 (R58) was a [AGE] year old female admitted to the facility on [DATE] with diagnoses that included obesity and anxiety. Review of the annual comprehensive Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 2/13/2026 had a signed completion date of 03/01/2026. During an interview on 04/16/26 at 9:41 am, with MDS float Nurse K, R58's MDS was reviewed. MDS float Nurse K reported the ARD of 02/13/26 should have a signed completion date of 2/27/2026. MDS Nurse K could not speak to why the former MDS nurse did not have R58's MDS completed timely.

Based on interview and record review, the facility failed to complete a quarterly assessment for three Residents (#49, #51, #61) of seventeen residents reviewed for comprehensive assessments.Findings Included:Resident #49 (R49) Review of the medical record revealed that R49 was admitted to the facility 05/08/2019 with diagnoses that included heart failure, chronic kidney disease, type 2 diabetes, atrial fibrillation, hyperlipidemia (high fat content in blood), epilepsy (neurological disorder with seizures), chronic pain, osteoarthritis (degenerative joint disease), osteoporosis (bone weaking), obesity, and chronic obstructive pulmonary disease (COPD). Review of R49's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/25/2025, revealed that R49 had a Brief Interview for Mental Status (BIMS) of 9 (moderate cognitive impairment) out of 15. Review of R49's medical record revealed that the last Minimum Data Set (MDS) was completed with an Assessment Reference Date (ARD) of 11/25/25.20 During an interview on 04/16/2026 at 09:40 a.m. Minimum Data Set (MDS) Nurse K explained that she was a float MDS Nurse K for the company that had ownership of the facility. MDS Nurse K explained that she had been assisting the facility because the facility MDS Coordinator was on leave. MDS Nurse K confirmed that R49 did not have quarterly MDS completed since 11/25/2025. MRDS Nurse K explained that there was no acceptable reason that R49 had not had quarterly MDS completed since 11/25/2025. Resident #61 (R61) Review of the medical record revealed R61 was admitted to the facility 09/13/2024 with diagnoses that included peripheral vascular disease (PVD), atrial fibrillation, hypertension, osteoporosis (bone weaking), hyperlipidemia (high fat content in blood), gastro-esophageal reflux disease, depression, dysphagia (difficulty swallowing) insomnia, and above left knee amputation. Review of R61's medical record revealed that the last Minimum Data Set (MDS) was completed with an Assessment Reference Date (ARD) of 12/05/2025. During an interview on 04/16/2026 at 09:40 a.m. Minimum Data Set (MDS) Nurse K explained that R61 was a due for a quarterly MDS on 03/07/2026. MDS Nurse K confirmed that the R61's last quarterly MDS was with an Assessment Reference Date (ARD) of 12/05/2025. MDS Nurse K could not explain why a quarterly MDS for R61 was not initiated for 03/07/2025. Resident 51 According to the clinical record, Resident 51 (R51) was an [AGE] year old female admitted to the facility on [DATE] with diagnosis that included chronic obstructive pulmonary disease. Review of R51's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/06/26 had signed completion date of 4/13/26. During an interview on 04/16/26 at 9:41 am, with MDS float Nurse K, R51's MDS was reviewed. MDS float Nurse K reported the ARD of 03/06/26 should have a signed completion date of 3/20/2026. MDS Nurse K could not speak to why the former MDS nurse did not have R58's MDS completed timely.

Based on observation, interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) assessment for one (R12) of 17 reviewed. Findings include:Review of the medical record reflected R12 admitted to the facility on [DATE], with diagnoses that included Alzheimer's and chronic obstructive pulmonary disease (COPD). The Annual MDS, with an Assessment Reference Date (ARD) of 3/4/26, reflected R12 scored four out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was coded as not having any applicable oral dental concerns. Broken or loosely fitting full or partial denture and no natural teeth or tooth fragment(s) (edentulous) were listed as coding options. On 04/14/2026 at 9:26 AM, R12 was observed seated in a wheelchair, in his room. R12 reported having dentures, but he had not seen them in a few months and did not know what happened to them. In an interview on 04/15/2026 at 11:40 AM, Licensed Practical Nurse (LPN) N reported R12 dropped and broke his dentures one to two months prior. In an interview on 04/16/2026 at 9:40 AM, MDS Nurse K reported that a quarterly observation and data collection, dated 2/5/26, reflected R12 had dentures. MDS Nurse K acknowledged R12's dental status was not accurately coded on the Annual MDS, with an ARD of 3/4/26.

Based on observation, interview and record review, the facility failed to revise the Care Plan for one (R9) of 17 reviewed. Findings include: Review of the medical record reflected R9 admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis (paralysis/muscle weakness on one side of the body) following cerebral infarction (stroke), affecting the left non-dominant side. The Significant Change in Status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/22/26, reflected R9 scored eight out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 04/14/2026 at 2:44 PM, R9 was observed lying in bed. In an interview on 04/15/2026 at 5:11 PM, Certified Nurse Aide (CNA) R reported R9 transferred via hoyer lift (mechanical lift that uses a sling to lift a person) and two-person assist. CNA R stated transfer status was included in the Care Plan. R9's Care Plan reflected an intervention, dated 11/9/21, for pivot transfers with assistance of one person. An intervention, dated 8/16/23, reflected one person assistance for stand and pivot transfers to the right side. An intervention, dated 4/12/23, reflected R9 transferred via hoyer lift and assistance of two people. A Physician Order, dated 1/23/26, reflected R9 transferred via hoyer lift with assistance of two people. In an interview on 04/16/2026 at 1:03 PM, Director of Nursing (DON) B reported R9 was downgraded to use a hoyer lift for transfers due to no longer being able to bear weight. DON B reported the transfer status on R9's Care Plan should have been updated.

Based on observation, interview, and record review the facility failed to implement pharmacy recommendations for one resident (#36) of five residents reviewed for pharmacy services.Findings Included:Resident #36 (R36)Review of the medical record revealed that R36 was admitted to the facility 11/04/2021 with diagnoses that included right ulna fracture, dysphagia (difficulty swallowing), depression, insomnia, anxiety, stroke, type 2 diabetes, hypertension, and pain. Review of the most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/01/2026 revealed that R36 had a Brief Interview for Mental Status (BIMS) of 07 (severe cognitive impairment) out of 15.On 04/14/2026 at 08:57 a.m. during observation R39 was observed lying in bed. R39 was pleasant during interview and expressed no concerns.Review of R36's medical record revealed a Pharmacist Drug Regimen Review, dated 07/29/2025, which stated Resident is receiving the statin: Atrovastatin. Please consider adding a fasting lipid panel with next lab draw and annually. The same document revealed the Response to Recommendation was marked Accepted. No order or results for a fasting lipid panel was located in R36's medical record.Review of R36's medical record revealed a Pharmacist Drug Regimen Review dated 09/16/2025, which stated Resident is receiving the statin: Atorvastatin. Please consider adding a fasting lipid panel with next lab draw and annually. The same document revealed the Response to Recommendation was marked Accepted. No order or results for a fasting lipid panel was located in R36''s medical record.During an interview on 04/15/2026 at 09:20 a.m. Director of Nursing (DON) B explained that a fasting lipid panel should have been completed based on the Pharmacist Drug Regimen Review recommendations which were completed 07/29/2025 and/or 09/16/2025. DON B confirmed that results of a fasting lipid panel were not present in R36's medical record and explained that she would attempt to locate the results.During an interview on 04/15/2026 at 10:07 a.m. Director of Nursing (DON) B explained that she was unable to find R36's results for a fasting lipid panel. DON B could not explain why the R36's pharmacy recommendations from 07/29/2025 and 09/16/2025 for a fasting lipid panel had not been ordered or completed.

Based on observation, interview and record review, the facility failed to ensure a timely dental services referral for one (R54) of two reviewed. Findings include: Review of the medical record reflected R54 admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis following cerebral infarction (stroke) affecting left non-dominant side and vascular dementia. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/26/26, reflected R54 scored three out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). According to the medical record, R54 had a Medicaid payer source.On 04/14/2026 at 1:36 PM, R54 was observed seated in a wheelchair, in her room. She reported she had seen the dentist for an issue with a tooth on the bottom, left side of her mouth. She reported she was supposed to do a follow-up but had not heard anything about it yet. A Dental consult for 9/12/25 reflected, .Patient complains of severe pain upon pressure from the posterior in the Lower Left as well as some in the Upper Anterior, left corner. Performed a visual oral exam. Explained to the Patient that she has a lot of fractured and hopeless teeth. Recommended that she gets all of her remaining Upper teeth and the lower fractured teeth removed by an Oral Surgeon .Patient states that she just wants to focus on the teeth causing the pain. Referred the Patient to the Oral Surgeon for removal of teeth #10, 11 and 18 . In an interview on 04/15/2026 at 11:40 AM, Licensed Practical Nurse (LPN) N the referral was never made for R54 to see the Oral Surgeon after her dental appointment on 9/12/25.

This Citation Pertains to Intake Number MI00152440. Based on interview and record review, the facility failed to ensure adequate supervision, implementation of meaningful and resident-centered care plan interventions, and staff awareness of planned interventions for fall prevention for two residents (Resident #701 and Resident #704) of three residents reviewed, resulting in Residents with a known risk of falls experiencing falls with injury, including a fracture, necessitating emergency medical treatment and unnecessary pain and discomfort. Findings include: Review of intake documentation revealed Resident #701 fell out of their bed on [DATE]. Per the intake, the Resident was then made to sit in a chair in the hallway so that staff could keep an eye on them and proceeded to have a second fall at appropriately 4:15 AM on [DATE] which resulted in the Resident having an open laceration on their head, which required transfer to the hospital for treatment and sutures in the Emergency Department (ED). Resident #701: Record review revealed Resident #701 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included dementia without behavior disturbance, heart disease, kidney disease, irritable bowel syndrome with diarrhea, and falls. Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed the Resident was moderately cognitively impaired, utilized a wheelchair for mobility, and required moderate assistance for transferring. Resident #701's Electronic Medical Record (EMR) revealed that the Resident was admitted to Hospice services on [DATE] and was discharged from the facility on [DATE]. Review of Resident #701's EMR revealed a care plan entitled, Resident is at risk for falling r/t (related to) dementia which could lead to poor safety awareness and choices, legally blind . (Start Date: [DATE]). The care plan included the interventions: - Provide non-skid footwear (Start Date: [DATE]) - Staff to assist resident with transfers as needed (Start Date: [DATE]) - Encourage resident to assume standing position slowly (Start Date: [DATE]) - Keep call light within reach (Start Date: [DATE]) - Offer restroom during rounds around 2a in an attempt to anticipate needs (Start Date: [DATE]) - Was started on trazadone for sleep on ,d+[DATE] for ,d+[DATE] observation on floor (Start Date: [DATE]) - Dysem to be placed above and below the wheelchair cushion (Start Date: [DATE]) - Offer assistance with antislip footwear as resident allows at HS (bedtime) and throughout the night if removes them (Start Date: [DATE]) - Offer activities if awake at night (****activities that does not require seeing- such folding towels, listening to music) (Start Date: [DATE]) - Bolster mattress to help define space (hospice to provide) (Start Date: [DATE]) A second care plan entitled, Profile Care Guide (Start Date: [DATE]) in Resident #701's EMR revealed the following interventions pertaining to fall prevention: - Falls/Safety: keep frequently used items in reach (Start Date: [DATE]) - Transfers: two person assist/pivot, gait belt (Start Date: [DATE]) - Walking/Mobility Devices: wheelchair (Start Date: [DATE]) An interview was completed with Family Member Witness C on [DATE] at 12:50 PM. When queried regarding Resident #701, Witness C stated, (Resident #701) died yesterday. With further inquiry, Witness C revealed Resident #701 was transferred to an inpatient hospice center from the facility on [DATE] and they passed away at the inpatient hospice facility. Witness C was asked about the care Resident #701 had received at the facility and verbalized they had concerns with multiple aspects of the care provided. When queried if the Resident had fallen in the facility, Witness C responded they had. Witness C stated, We got a call that (Resident #701) fell out of their wheelchair at 4:30 in the morning and was going to the hospital. Witness C stated they asked the facility staff member who called them what happened and were told, I can't tell you because I don't want to implicate anybody. Witness C revealed they found out that Resident #701 had fallen earlier in the night in their room. When queried, Witness C stated, I was told (Resident #701) was naked in the corner of the room. When queried if they were provided any additional information as to how the Resident was found naked in the corner of their room, Witness C revealed they were not and did not know how the Resident had fallen. Witness C revealed they went there because they wouldn't tell me the CNA (Certified Nursing Assistant) who was working when (Resident #701) fell . Witness C revealed they wanted to know as they had concerns with specific CNA's not addressing the Resident's needs. Review of documentation from [DATE] in Resident #701's EMR revealed the Resident had two unwitnessed falls from their bed and two unwitnessed falls from their wheelchair. Documentation in Resident #701's EMR detailed the following: - [DATE] at 8:15 PM: Nursing . Incident Report . IDT note for fall event from [DATE]. Resident was observed in room in wc (wheelchair) then observed on floor by staff. Resident is legally blind has dementia . resident is on hospice care requires assistance to transfer . Dysem applied to top/bottom of wc cushion to prevent any sliding out of wc . - [DATE] at 3:50 AM: Nursing . Incident Report . [DATE] at 3:00 AM . Fall . Resident room . Observed on the floor. Did resident hit head? Unknown . Indicate new measures taken to prevent reoccurrence.: Other hospice consult . - [DATE] at 7:09 AM [Recorded as Late Entry on [DATE] 07:09 PM]: IDT note for fall incident on ,d+[DATE] . Resident had fall in middle of night . blind and partly deaf uses hearing aides during day time. Resident is poor historian also has dementia was barefoot upon time of fall. Intervention- offer assistance with antislip footwear as resident allows at HS and throughout the night if removes them . - [DATE] 11:14 PM: Event . Date/Time of Incident: [DATE] 10:12 PM . Fall . Location: Resident Room . Witnessed: No . Injury . Laceration/Abrasion . Other: Bump on forehead . What was the resident doing prior to fall . In bed sleeping . What type of footwear did the resident have on? . Regular socks . - [DATE] at 11:38 PM: Nursing . Incident Report . What was date and time of occurrence? [DATE] 10:12 PM . Fall, Laceration/Abrasion . Resident room type of fall . Observed on the floor . Did resident hit head? Yes . exhibit or complain of any new pain? Yes . Forehead sore . Was resident sent to the hospital? No . new measures taken to prevent reoccurrence.: Bed in lowest position, Night light placed . immediate treatments were given? Cold packs. How many lacerations/abrasions? 2. Laceration/abrasion 1: Length: 1.5 cm (centimeter) . Width: 5.0 cm . Depth: 0.5 cm . location of the laceration/abrasion?: Right side of forehead . Laceration/abrasion 2: Length: 1 cm . Width: 1.5cm . Location of the laceration/abrasion?: Right eye brow . New measures taken to prevent reoccurrence.: Apply moisturizer to keep skin supple, Monitor for edema . - [DATE] at 11:46 PM: Incident Report . Resident's roommate came out of the room to report that resident had fallen out of bed. Writer and nursing assistant went to room and observed resident laying on the floor on right side. Neuro check initiated. Resident has abrasion on the right side of forehead and the right eye brow. Tender to touch. Resident assisted back to chair . - [DATE] 5:48 AM: Event . Date/Time of Incident: [DATE] 4:20 AM . fell out of wc . Fall . Skin tear . Hallway . Was incident witnessed? No . Injury . Skin tear . Was safety equipment in place and functioning at time of fall? None ordered . Indicate if any of the following factors are present? Cognitive or memory impairment . Difficulty understanding or following directions . Impaired vision . Requires assistance to transfer . Requires assistance to ambulate with or without assistive device . - [DATE] 4:40 AM [Recorded as Late Entry on [DATE] 05:24 PM]: Nursing . 4:40 AM: At approximately 0420 (AM) writer was leaving [NAME] Hallway and observed resident on the floor near [NAME] Hallway. While making my way to the resident I observed the other nurse on [NAME] Hallway and informed them of what had happened. Upon reaching the resident I observed (Resident #701) laying on left side in front of their wheelchair. Resident had a moderate amount of blood on head and on the floor around head. I cleaned away the blood as much as possible and observed a bump and laceration on the R side of resident's forehead. Laceration was still actively bleeding, light pressure was applied. Resident was repeating my leg, my leg but was not able to state which leg was bothering them or how they had ended up on the floor. EMS arrived approximately 0430 (AM) and took over care. Writer had last observed resident approximately 10 minutes prior sitting calmly in wheelchair . - [DATE] at 4:40 AM: Nursing . Incident Report . At approx. 04:20 (AM), res. was observed on hard floor in common area in front of w/c (wheelchair). Res. was laying on left side with forehead against floor. Res. Had moderate amount of blood loss from skin tear on forehead with continued bleeding. Res. c/o (complain of) leg pain but would not specify which leg . last observed sitting in w/c by multiple staff members at approx. 04:15 (AM). - [DATE] at 4:52 AM: Res. had been up in chair since fall at beginning of shift. Res. up in w/c near nurse station, propelling self in w/c and conversing with staff. Res. was asked multiple times throughout the night if would like to go to bed and declined . Snacks and drinks offered and declined. - [DATE] at 5:06 AM: Telehealth - Asynchronous . Resident had another fall tonight but did hit head this time, RN (Registered Nurse) noted a pool a blood coming from a skin tear on forehead, they were able to get the bleeding to slow . sent to the hospital for further evaluation . - [DATE] at 7:34 AM: Another family member is present and whom called the police writer called DPOA (Durable Power of Attorney -Witness C) to inquire of an update of resident and advise that writer will be calling hospice to update . - [DATE] at 9:22AM: Nursing . Returned from ER per ambulance. Resident awake, answering questions. Drsg (Dressing) to head dry and intact . Bruise noted right knee . - [DATE] at 9:36 AM: Nursing: 6 sutures 1.5 cm long laceration surrounding skin is light pink abrasion, old bruise to R forearm anterior aspect, new right knee light green bruise, denies pain able to move leg . Small bruise (red in color) less than 0.5 cm to face near corner to skin of L eye Right eyebrow abrasion no scab formation no bleeding noted. some blood noted to be dried consistent with the bleeding from forehead laceration . - [DATE] at 9:47 AM: Skin Integrity Events . Description: Laceration to R side of forehead . Describe location of incision: right side forehead superior to eyebrow . Length . 1.2 cm (centimeters) . Width: 0.2 mm (millimeters) . Exudate . Scant . Sanguinous (bloody) . Wound approximated with? Staples (number) - 6 . - [DATE] at 9:50 AM: Incident Report . IDT note for incident event (fall) on [DATE]. Resident rolled out of bed, roommate said (Resident #701) was holding on and almost lowered self to floor but could not hold on and place on call light for staff to assist. Resident bed was in lowest position, call light was in reach although not on as resident did not put it on. resident had socks on while in bed. resident sustained a minor non-bleeding abrasion almost rug burn like appearance to forehead requiring no first aide or treatment will monitor open to air . INTERVENTION- Approach: bolster mattress to help define space (hospice notified of this and are going to provide). RAI -care guides updated. Goal is to remain free from falls . - [DATE] at 9:55 AM: Incident Report . IDT note for incident event (fall) on [DATE]. BIMS is 9. resident is a poor historian and hx (history) of Alzheimer's dementia. Resident s/p (status post) second fall . was up with staff in wc as already rolled out of bed and seemed to be restless in bed, did better in wc . (CNA) advised to writer that resident made it clear all her needs were met prior to assisting another resident and told the resident she will be right back after helping someone else. resident was sitting upright in wc at 415 am last noted by (CNA). Upon the (CNA) being in another room, the floor nurse was passing medications to another resident on another floor at this very time. resident was then observed by the other nurse whom was not assigned to (Resident #701) from afar this was around 420am . Resident sustained abrasion to R forehead and was bleeding from a skin tear same location and pressure was applied but bleeding continued so on call provider ordered to send for eval and tx (treatment) . INTERVENTION- Send to ER for evaluate and tx. in addition will offer activities if awake at night (activities that do not require visualization such folding towels, listening to music) . Review of Resident #701's Hospice documentation revealed a note dated [DATE] which detailed, RN (Registered Nurse) . visit following (Resident #701's) return from ED related to fall. Spoke to (RN E), stated . (Resident #701) rolled out of bed at 10:00 PM on [DATE]. (Resident #701) ws brought out to a common area and self-propelling, then fell out of wheelchair on hard vinyl floor causing laceration to right forehead. Due to bleeding . was sent to ED . When (Resident #701) returned, family was unhappy with care, unsure of how (the Resident) fell and stated neglect . called 911, filed a police report and the facility is performing an investigation . (Resident #701) was put in wheelchair following fall out of bed as was awake and tends to be restless . completed assessment with (facility staff). Noted: Dry blood in hair, 1.5 inch laceration with 6 sutures to right forehead, small bruise to right side of right eye, abrasion above right eye/forehead, large bruise to right knee . (Resident #701) is alert, asking 'What do we do' and 'Help me' . confused at baseline . Hospice RN encouraged use of bolster mattress and to offer activity like folding towels or listening to music as (Resident) is blind to (Resident) when awake and not sleeping at night as new interventions, (facility nurse) entered into care plan. Hospice to order mattress . Discussed event with (Witness C) . extremely unhappy with care at facility, how the event happened and staffs lack of care and communication . listened and supported by active listening and validating concerns . An interview was completed with Registered Nurse (RN) D on [DATE] at 9:16 AM. When queried if they recalled Resident #701, RN D responded that they did. RN D was queried regarding the level of assistance Resident #701 required and replied, (Resident #701) was hard of hearing, couldn't see, had dementia very bad, and wouldn't follow directions. RN D revealed the Resident was a two-person pivot transfer. RN D continued, It was turning for a pivot transfer that seemed to cause (Resident #701) pain and indicated the Resident would become combative with care. When asked if the Resident became combative because they were in pain, RN D indicated it was possible or could have been because they couldn't hear or see and didn't understand what staff were asking them to do. RN D then stated, They were going to start (Resident #701) on Seroquel (antipsychotic medication with black box warning for use in elderly) just before (Resident #701) went on hospice but (Witness C) wanted (the Resident) put on Zoloft (antidepressant medication) instead. When queried why Seroquel was discussed, RN D replied, At night, (Resident #701) would yell out. RN D then stated, Zoloft was not really effective. It was like (the Resident) would get in a loop and ask the same thing it was like you had to be constantly engaged with them. An interview was completed with Confidential Witness F on [DATE] at 9:45 AM. When queried regarding Resident #701, Witness F stated, (Resident #701) did fine if someone sat with them and helped them. When queried if they were present when the Resident fell , Witness F indicated they were not but verbalized the Resident would become restless if left alone due to being blind and hard of hearing. An interview was completed with the facility Administrator on [DATE] at 1:50 PM. When queried if there was any additional facility investigation documentation pertaining to Resident #701's falls in [DATE], other than the event documentation, the Administrator stated, The investigation stuff was submitted with a five-day investigation that was closed for neglect. The Administrator was asked to review the investigation documentation and replied, The staff followed the fall care plan. The Administrator then stated, I will get (Assisted Living [AL] Director, Licensed Practical Nurse [LPN]) B. They can talk you through it. An interview was completed with AL Director B on [DATE] at 2:02 PM. When queried if staff involved in Resident #701's falls were interviewed, Director B indicated they were and provided Statement of Witness forms for RN I, CNA J, and RN K. All the Statement of Witness Forms specified the interviews were conducted by RN E. Review of the statements detailed: - RN I - Date of Interview: [DATE]: I called (Witness C) and spoke with them in regards to both falls including at 10ish PM. No injuries, just abrasion no bleeding to forehead. Aide (CNA) got (Resident #701) in WC, self-propelling around hall wall and nurse station. Offered snacks drinks and to lay down every so often, Res declined. (Resident) made it clear was happy and content in wc and needed nothing. Went to pass meds on (different facility hallway). Last seen in wc on hallway sitting upright . While on (different hallway), other nurse came and told me Resident had fall, I went to assess . - CNA J - Date of Interview: [DATE]: Did shift change at beginning of hallway. Call light was on mid-report. 2nd shift aide answered light. Observed on floor as I walked behind (Resident #701). I helped transfer to bed, appeared not tired to I transferred to wc. Nurse sat with resident in between call lights. Time passed. Toileted just after 3:00 AM. Went to toilet another resident on hallway and (RN K) observed Resident on floor. Last seen about 4:1AN, When came out of other resident room was on floor next to wc area/hard floor area before [NAME] ([NAME]). Hallway. Prior to going to other resident room (Resident #701) wasn't want to eating/drink/no pain/good position in wc. Needs appeared met . - RN K - Date of Interview: [DATE]: I was walking off [NAME] (hallway) and seen (Resident #701) from afar on the floor at edge/front of [NAME] (hallway) - not on carpeted area. Upon walking/hurrying to get (Resident #701), their nurse was on [NAME] (other hallway) told them of (Resident #701) on floor and placed towel to forehead was bleeding. When queried if they completed the interviews, Director B responded that RN E was the weekend supervisor and had completed the interviews with the staff who were working when the incident occurred. Director B was then asked about documentation from the fall on [DATE] detailing the Resident was wearing regular socks and not non-slip footwear, Director B confirmed the Resident had on regular socks per the documentation. When asked why Resident #701 did not have non-slip footwear in place as per the care plan intervention following their previous fall from bed, Director B was unable to provide further explanation. When queried what intervention the staff implemented following the Resident's first fall, Director B reviewed the Resident's care plan and indicated a bolster mattress. When queried if that intervention was immediately implemented, Director B confirmed it was not and revealed the Resident was put in a wheelchair to be within view of the nursing staff. When asked, Director B confirmed the Resident's second fall occurred when they were in the wheelchair. Director B was asked where facility staff were when the Resident fell and responded that the nurse was on a different hallway passing medications and the CNA was in a room providing care to another Resident. When queried regarding staffing assignments, Director B revealed nurses are assigned to two halls and there is one CNA per hallway. When asked if Resident #701 was incontinent when they fell from their wheelchair, as they were last toileting by the CNA around 3:00 AM, Director B revealed they were unsure as the fall documentation did not specify. When asked what the facility determined the Resident was attempting to do when they fell , Director B indicated the Resident was self-propelling in their wheelchair but was unable to provide further explanation. When asked why the Resident was left unattended and unsupervised after having been supervised by nurse, according to the notes, given the Resident was blind, hard of hearing, and had severe dementia/confusion, Director B indicated the CNA checked on the Resident before going to provide care to a different resident but did not provide further explanation. Resident #704: At 12:10 PM on [DATE], Resident #704 was not in their room. The room was located approximately midway down the hallway and not near the central area of the facility and/or nurses' station. No notable fall prevention interventions were present in the room. On [DATE] at 12:15 PM, Resident #704 was observed sitting in a wheelchair at a table in the dining room of the facility. The Resident's wheelchair had bilateral leg/footrests in place and the Resident's feet were positioned on the footrests. When asked questions, the Resident made eye contact but did not provide verbal responses. Review of the CMS-802 Form detailed Resident #704 had a fall with major injury. Record review revealed Resident #704 was originally admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, dementia with other behavioral disturbance, anxiety, right foot hallux rigidus (limited movement, stiffness, pain in the big toe joint), falls, and displaced fracture of the right femur with surgical repair. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required substantial to maximum assistance to complete Activities of Daily Living (ADL), moderate assistance with transfers, and had one sided lower extremity Range of Motion (ROM) impairment. Further review revealed Resident #704 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. On [DATE] at 8:30 AM, Resident #704 was observed sitting in a wheelchair in the dining room of the facility. The Resident's wheelchair was positioned far from the table, approximately one foot away. Both of the Resident's feet were positioned on the leg/footrests of the wheelchair. Resident #704 was observed lifting the plate of food to bring it closer to them. The Resident then picked up a fried egg with their finger and began to eat it. When asked questions, Resident #704 made eye contact but did not provide meaningful responses. An interview was completed with Registered Nurse (RN) L on [DATE] at 8:40 AM. When queried regarding Resident #704, RN L stated, (Resident #704) is alert and oriented to self only. RN L further explained that the Resident was very confused and required assistance and cueing for all tasks including eating. RN L stated, (Resident #704) doesn't remember me from day to day. When asked how long the Resident had been at the facility, RN L stated, (Resident #704) went to the hospital and came to this side after. They fell and fractured their hip. With further inquiry, RN L explained the Resident was originally admitted to the 400-hall of the facility, they fell and were sent to the hospital where they had surgery due to fracturing their hip and were admitted to the 100-hallway when they returned to the facility. When queried, RN L revealed Resident #704 was originally admitted to the facility for therapy because they fell and fractured their right hip then they fell and fractured their left hip while at the facility. On [DATE] at 1:11 PM, an interview was completed with Family Member Witness M. When queried regarding Resident #704's stay in the facility and fall, Witness M stated, (Resident #704) went (to the facility) because they broke their right hip and then fell while there and broke their left hip. That kind of bothered me. When queried what bothered them, Witness M revealed what they were told by facility staff about what happened did not make sense. Witness M was asked what they were told and stated, The first call they said we found (Resident #704) in a corner and said (the Resident) took off all their clothes. Witness M revealed the staff told them Resident #704, Took the sheets off the bed and wrapped themselves in it and that they put (Resident #704) back in their bed. When asked if they were aware of a reason the Resident may have removed their clothes and if that was something the Resident had done previously, Witness M verbalized that was not normal for Resident #704. Witness M continued, Then they called me around 9:00 AM the next morning and said the Doctor was on their rounds, checked (Resident #704) out, and had a big bruise so they were going to send them out to the hospital. When asked what happened, Witness M stated, (Resident #704) went to the hospital and they said (the Resident) broke their left side (hip) too. Witness M declared, I never got the truth out of them (facility staff) of what actually happened. It doesn't make sense. When asked, Witness M revealed they did not understand how or why Resident was found in the corner and why staff were not monitoring them. When queried if Resident #704 was able to use the call light when they need assistance, Witness M replied, Won't call for help and indicated the Resident does not remember the call light or that they need assistance. Review of Resident #704's Electronic Medical Record (EMR) revealed a care plan entitled, Falls- Resident is at risk for falling r/t (related to) broken bones (Start Date: [DATE]). The care plan included the interventions: - Ensure the floor is free of liquids and foreign objects (Start Date: [DATE]) - Keep call light within reach (Start Date: [DATE]) - Staff to assist resident with transfers as needed (Start Date: [DATE]) - Encourage resident to assume standing position Slowly (Start Date: [DATE]) A second care plan entitled, ADL's: Profile Care Guide (Start Date: [DATE]) was also present in Resident #704's EMR. This care plan included the interventions: - Falls/Safety: high fall risk (Start Date: [DATE]) - Other: not oriented to name, place, time, or date (Start Date: [DATE]) - Transfers: two person assist, gait belt, no ambulating at this time per therapy, 2PA (Person Assist) with lower body dressing, transfers and bed mobility-reposition q (every)2 hr while in bed, 1PA for upper body dressing and hygiene wbat (weight bearing as tolerated) lle (left lower extremity) (Start Date: [DATE]) - Walking/Mobility Devices: unable to ambulate, 2PA for transfers/toileting WBAT to LLE, activity as tolerated total hip replacement protocol WITHOUT need to follow hip precautions (Start Date: [DATE]) Review of documentation in Resident #704's EMR revealed the following: - [DATE] at 1:32 PM: Admission Observation . Prior surgeries in last 100 days, describe - right hip . Foot Press Strength: Weak bilaterally . Baseline Care Plan Goal- Resident will have no negative outcomes related to vision, hearing, oral and dental status . Desired Approaches: Encourage Resident to wear eyeglasses and assist with keeping them clean. Offer and provide dental/oral care as needed. Ensure adequate lighting in room. Report any oral/dental issues to social services for referrals as needed. Orient to objects and layout of the room Assist with hearing aids as needed . Musculoskeletal . Left Lower extremity - weak . Right Lower extremity - weak . Assistive Devices: Wheelchair . Weight Bearing: Full . Safety: Falls Risk Review . Did the resident have a fall any time in the last month . Yes . Fall Risk Score: 22 Level: High . Baseline Care Plan Goal- Resident will remain safe and free of major injury related to falls . Desired Approaches: Encourage Resident to assume a standing position slowly. Therapy eval and treat as ordered. Call light within reach . Personal items within reach . Non-skid footwear Observe for signs of wandering or exit seeking and notify MD as needed. Assure floor is free of foreign objects . Fall history . desired approaches . PT/OT/ST eval and treat as ordered . 2 person assist until therapy evaluation. Assess Pain every shift. Proper fitting shoes . Bed Mobility: Extensive Assistance . Transfers: Extensive Assistance . Toileting: Extensive Assistance . - [DATE] at 8:50 PM [Recorded as Late Entry on [DATE] 12:15 PM]: Nursinng . Incident Report . This writer was notified by (Certified Nursing Assistant - CNA) that the resident was observed on the floor next to the bed in the resident's room. Upon entering the room the resident was observed to be without a gown or brief on. Resident had removed clothing items. Staff was attempting to provide care with the resident swatting and pulling at the staff. Resident was also observed to be verbalizing nonsensical word salad during observations. No visual signs of injury were observed, no bruising noted. Unable to perform range of motion due to the resident moving all four limbs while being combative with staff. Grip strength was unable to be determined due to resident's inability to follow directions. Neuro checks were initiated and found to be within normal for the resident. Resident appears to be within base line. On call provider called and no new orders were received and responsible party was notified . - [DATE] at 9:08 PM: Nursing . Incident Report . date and time of occurrence? [DATE] 8:45 PM . Fall . Resident room . Observed on the floor (Unwitnessed) . Did resident hit head? No . Does resident exhibit or complain of any new pain? No. Range of Motion: ROM x 4 without pain/limitations. Positioning of extremities: No rotation/deformity/shortening noted. Was resident sent to the hospital? No. Indicate new measures taken to prevent reoccurrence: Bed in lowest position, Monitor for pain . - [DATE] at 4:13 AM: IDT note for incident fall on ,d+[DATE]. Resident poor historian, BIMS 0 (severely cognitively impaired). Resident observed on floor by staff . no injuries post fall noted by nurse notes/fall event assessment by floor nurse. Fall protocol initiated . Neuro assessments at resident baseline. Nursing will continue fall protocol and perform neuros per orders and VS (Vital Sign) assessments, along with pain assessment. Intervention: Staff to assist Resident with transfers as needed. Keep call light in reach and clip to resident shirt/gown as allows to help remind to use. Winged mattress to help define space . - [DATE] at 6:45 AM: Nursing . This RN rounded on res. multiple times during shift and res. observed to be restless and anxious during rounds. During rounds this RN offered res. Prn (as needed) medications, water, and repositioning. Res. refused offers for care and treatments. Per (CNAs) when toileting res. was observed to be combative and yelling out. - [DATE] at 8:26 AM: Nursing . This nurse went into residents room to obtain vitals and admini [TRUNCATED]

This Citation Pertains to Intake Number MI00152440. Based on observation, interview and record review, the facility failed to ensure Activities of Daily Living (ADL) and hygiene care were provided to one resident (Resident #704) of three residents reviewed. Findings include: Resident #704: On 5/6/25 at 12:15 PM, Resident #704 was observed sitting in a wheelchair at a table in the dining room of the facility. The Resident's fingernails were long. When asked questions, the Resident made eye contact but did not provide verbal responses. Record review revealed Resident #704 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's disease, dementia with other behavioral disturbance, anxiety, right foot hallux rigidus (limited movement, stiffness, pain in the big toe joint), falls, and displaced fracture of the right and left femurs with surgical repair. Review of the Minimum Data Set (MDS) assessment, dated 4/15/25, revealed the Resident was severely cognitively impaired and required substantial to maximum assistance to complete Activities of Daily Living (ADL), and moderate assistance with transfers. On 5/7/25 at 8:30 AM, Resident #704 was observed sitting in a wheelchair in the dining room of the facility. The Resident's wheelchair was positioned far from the table, approximately one foot away. Resident #704 was observed lifting the plate of food to bring it closer to them. The Resident then picked up a fried egg with their finger and began to eat it. Resident #704's fingernails were long and uneven with a dark colored, unknown substance visible under their nails. When spoke to, Resident #704 made eye contact but did not provide meaningful responses to questions when asked. An interview was completed with Registered Nurse (RN) L on 5/7/25 at 8:40 AM. When queried regarding Resident #704, RN L stated, (Resident #704) is alert and oriented to self only. RN L further explained that the Resident was very confused and required assistance and cueing for all tasks including eating. RN L stated, (Resident #704) doesn't remember me from day to day. When queried regarding observation of the Resident picking up and eating their egg with their hands, RN L stated, (Resident #704) needs cueing and is independent for eating. RN L verbalized the Resident does better with finger foods. With further inquiry regarding the Resident's lack of meaningful communication but being more interactive today than yesterday, RN L indicated the Resident had a rough day yesterday and stated, (Resident #704) had a big BM (bowel movement) yesterday and is hands everywhere so they had their hands in the BM. When queried if the Resident is able to complete any of their own hygiene activity including washing their hands, RN L revealed the Resident requires assistance primarily due to loss of cognition. An observation of Resident #704 was completed in the dining room of the facility with Assisted Living Director B on 5/7/25 at 9:00 AM. Resident #704 was observed sitting in their wheelchair in the same place/position as prior observation. Director B was asked to look at Resident #704's fingernails, including the underside of the nails. When asked what they saw, Director B confirmed the Resident had a dark colored, unknown substance under their fingernails and verbalized they would address immediately. On 5/7/25 at 1:11 PM, an interview was completed with Family Member Witness M. When queried regarding the care Resident #704 receives at the facility, Witness M verbalized multiple concerns including ADL care and feeding assistance. When asked how often they visit the Resident, Witness M replied, I just went to their doctor appointment with them. When asked if they had any concerns regarding the hygiene care provided at the facility, Witness M verbalized concern regarding the Resident's fingernails. Witness M verbalized Resident #704's nails were very long and had not been maintained and/or cut. Witness M indicated a Certificated Nursing Assistant (CNA) had told them they would cut their nails when they asked, but it had not happened. Review of Resident #704's care plans revealed a care plan entitled, ADL's: Resident requires staff assistance to complete self-care and mobility functional tasks completely and safely (Start Date: 4/29/25). The care plan included the intervention, Provide nail care on shower days and PRN (as needed) (Start Date: 4/29/25). On 5/7/25 at 2:02 PM, an interview was conducted with Director B. Director B verbalized they spoke to the direct care staff regarding Resident #704's nails. A review of Resident #704's Electronic Medical Record (EMR) did not reveal specific documentation related to completion of nail care and/or hand hygiene. An interview was conducted with the facility Administrator and Director B on 5/7/25 at 4:52 PM. When queried regarding observation of Resident#704's fingernails while eating with their hands, the Administrator verbalized understanding of concern. No further explanation was provided. Review of facility policy/procedure entitled, Nursing ADL Documentation Guidelines (Dated: 5/10/16) did not include information pertaining the provision of ADL and/or hygiene care.

Based on observation, interview and record review the facility failed to ensure accurate Minimum Data Set (MDS) assessments for four (Resident #4, #34, #42, and #67) of 18 reviewed. Findings include: Resident #4 (R4) Review of the medical record revealed R4 admitted to the facility on [DATE] with diagnoses that included major depressive disorder. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/2/24 revealed R4 scored 14 out of 15 (cognitively intact) on the brief interview for mental status. Review of the Annual MDS with an ARD date of 12/2/24 revealed R4 was coded for taking an anticoagulant medication and an opioid medication. Review of the Physician Orders revealed R4 was not taking an anticoagulant or an opioid medication for that MDS period. In an interview on 1/29/25 at 12:23 PM, MDS coordinator B reviewed the MDS and reviewed the Physician Order's for R4 and agreed that R4 was coded for taking an anticoagulant medication and opioid medication inaccurately. Resident #42 (R42) Review of the medical record revealed R42 admitted to the facility on [DATE] with diagnoses that included adjustment disorder with mixed anxiety and depressed mood. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/17/25 revealed R42 scored 10 out of 15 (cognitively impaired) on the brief interview for mental status. Review of the Physician Orders revealed R42 was taking an antipsychotic medication. Review of the MDS with an ARD date of 1/17/25 revealed R42 was not coded for taking an antipsychotic mediation. In an interview on 1/29/25 at 12:23 PM, MDS coordinator B reviewed the MDS and reviewed the Physician Order's for R42 and agreed that R42 should have been coded for taking an antipsychotic medication. 34705 Resident #34 (R34) Review of the Face Sheet and Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/4/24, reflected R34 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), malnutrition and depression. The MDS reflected R34 had a BIM (assessment tool) score of 10 which indicated his ability to make daily decisions was moderately impaired. During an observation and interview on 1/27/25 at 11:45 AM, R34 was in room sitting in wheelchair with some difficulty answering questions. R34 family was present and reported was currently receiving hospice services. Review of R34's Physician Orders, dated 9/26/24, reflected an order for Hospice services. Review of R34's Significant Change MDS, dated [DATE], reflected no evidence that resident 34 was on Hospice services. During an interview on 1/28/25 at 4:44 PM, MDS staff C reported had been in position about five months and received support from regional support staff. MDS C reported MDS significant change needed to be completed if hospice services add or permanent decline in two areas or improvement in two areas. MDS staff C verified R34 was currently on Hospice services and started 9/26/24. MDS staff C reported R34's significant change MDS was most likely completed related to adding Hospice services and verified Hospice Services was not marked on assessment and should have been. MDS staff C reported must have been an oversight and would plan to submit correction. 49103 Resident #67 Review of the medical record revealed R67 admitted to the facility on [DATE] with diagnoses that included Unspecified Displaced Fracture of first Cervical Vertebrae. During review of the Electronic Medical Record (EMR) it was noted that the Discharge Minimum Data Set (MDS) dated [DATE] revealed R67 was coded as having discharged to hospital. Review of the EMR revealed R67 discharged home on 12/13/2024 at 11:27 AM as revealed by documentation entered by the Nurse Practitioner (NP) Y. On 01/29/25 at 03:31 PM during interview with Social Worker (SW) Z the MDS was reviewed and SW Z stated, She did go home with spouse and I am not sure why the MDS reflects otherwise. She discharged home. On 01/29/25 at 03:39 PM SW Z explained, I followed up with the MDS Coordinator and it was selected in error. And we are submitting for a modification.

Based on observation, interview and record review, the facility failed to ensure appropriate storage of medications, including narcotics in 2 of 5 medication carts, resulting in the potential for misuse, and medication administration errors. Findings include: During an observation on 1/28/25 at 9:15 AM, 100 hall medication cart was unlocked with no staff present. Continued observation with two non-nurse staff members passing medication cart. Observed nurse staff exit resident room and return to medication cart and lock cart at 9:18 a.m. prior to exiting hall 100. Review of the 100 hall medication cart on 1/28/25 at 11:22 AM, Registered Nurse (RN) K unlocked 100 hall medication cart, revealed a unlabeled medication cup with at least 2 unidentified pills in the top drawer. RN K grabbed the cup of medications and reported was resident 11:00 am medications and needed to administer medications now, locked medication cart and entered resident room [ROOM NUMBER]. This surveyor heard RN K tell resident she had her Norco and Tramadol(Controled narcotics). RN K returned to the medication cart and opened cart. Continued review of the cart revealed one single blister pack levoquin 250mg in top drawer with no name and one pharmacy packaged Levaquin 750mg with resident name. RN K reported was unsure why they were in top drawer and should not be. Continued review of the medication cart revealed several open eye drops with no open dates delivered in past 30 days. RN K obtained treatment ointment for another resident from treatment cart near by while surveyor continued to review medication cart and stood by this surveyor with gloves on. After cart review RN K asked if complete and left cart without locking and entered another resident room about 4-5 doors down hall at 11:39 a.m. This surveyor continued to observe 100 unlocked medication cart until RN K exited resident room, returned to medication cart and locked at 11:44 a.m. During an interview on 1/28/25 about 3:40 PM, DON B reported would expect medication carts to be locked if nurse steps away, and controlled drugs should be double locked. DON B reported would not expect Levaquin to be located in top draw of medication carts and each resident medications should be located in middle drawers separated by resident and labeled with resident name and medication. DON B medications should not be prepped in advance in unlabeled medication cups and stored in medication carts prior to administration because that can increase risk of medication errors. DON B reported would expect nurses to document at the time medication was administered. Review of the provided, Medication Storage in the Facility Policy, dated 11/18, reflected, The provider pharmacy dispenses medications in containers that meet regulatory requirements, including standards set forth by the United States Pharmacopoeia (USP). Medications are kept in these containers. Facility personnel may not transfer medications from one container to another or return partially used medications to the original container .Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medication .are permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons wit authorized access . 46954 An observation on 01/28/25 11:52 AM of the [NAME] medication cart with Registered Nurse (RN) B, revealed a medication cup with 6 unidentified pills. There was a piece of paper in the cup with a possible resident name written on the paper. RN B reported the medications should not be stored in a medication cup inside the medication cart.

Based on observation, interview, and record review the facility failed to provide Activities of Daily Living (ADL's), including bathing/showering for one dependent resident (R4) reviewed of ADL care, resulting in increased likelihood of feelings of worthlessness, disrespect and the potential for uncleanliness. Resident #4(R4) Review of the Face Sheet and Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/2/24 , reflected R4 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure), venous insufficiency (decreased blood flow in legs), cirrhosis of the liver (decreased liver function), pressure ulcer stage III, and depression. The MDS reflected R4 had a BIM (assessment tool) score of 14 which indicated her ability to make daily decisions was cognitively intact, and she required partial to moderate assist with transfers, dressing, and bathing. During an observation on 1/27/25 at 10:04 AM, R4 was in room sitting in wheelchair and appeared upset, dressed and hair appeared un-groomed. When asked if R4 had any concerns with care at facility R4 stated, does it look like I should have concerns? and looked at the bed. R4 reported was unhappy because staff removed sheet from bed and left dirty sheets on end of bed and have not returned. R4 reported staff had not changed sheet for two weeks. R4 reported was scheduled for showers two times weekly on Sunday and Thursday and did not get shower yesterday. Review of R4's Electronic Medical Record Bathing records, dated 11/29/24 through 1/29/25, reflected R4 had 10 missed showers with several entries of, activity did not occur. Review of R4 Care Plans, dated 2/11/21, reflected interventions that included, Assist with ADL care as needed .4/6/22 Resident may ambulate from room to DR[dining room] with 4WW[4 wheel walker] SBA[stand by assist] x 1 person with w/c follow and right knee brace .Supervision with bathing . During an interview on 1/29/25 at 12:50 PM, Certified Nurse Aid (CNA) G reported residents usually received showers 2 x weekly according to room number. CNA G reported R4 was a female only for caregivers and can often just trade female CNA to complete care needs. During an interview on 1/29/25 at 1:00 PM, Director of Nursing (DON) B reported residents usually have showers scheduled 2 times weekly and staff document in EMR under tasks. DON B reported staff have shower schedules according to rooms that have already been approved by residents. DON B reported if staff do not have time to shower residents they are expected to communicate to next shift and offer shower, if not offer the next morning. DON B reported if residents refuse would expect CNA staff to offer three times over 15 minutes apart and if still refused to report to nurse who should completes Progress Note. DON B reported noticed about two weeks ago R4 had several did not occur on shower documentation and staff was educated. Documentation reflected R4 was not provided shower on 1/26/25 as scheduled with no supporting documentation.

This citation pertains in intake MI00148900. Based on observation, interview, and record review, the facility failed to ensure care and services was provided for two of 17 residents (R3 and R4) reveiwed resulting in a delay in treatment to maintain the highest practical level of wellbeing and care needs not being met. Findings include: Resident #3 (R3) Review of the medical record reflected R3 was an initial admission to the facility on [DATE] and readmitted on [DATE]. Diagnoses of fracture of upper end of right tibia, subsequent encounter for closed fracture with routine healing, presence of right artificial knee joint, periprosthetic fracture around internal prosthetic right hip joint, arthritis of left hip, muscles weakness, difficulty walking, Type 2 Diabetes Mellitus with Diabetic Kidney Disease, and Depression. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/19/2024, revealed R3 had a Brief Interview of Mental Status (BIMS) of 13 (cognitively intact) out of 15. Under section GG0100, Activities of Daily Living (ADL) Assistance reveals R3 was dependent on all care and requires minimal assist with setting up for meals and oral care. During an interview on 01/28/25 at 12:14 PM, R3 stated she had just got back from physical therapy and the Certified Resident Care Assistant (CRCA) would be in to transfer her from the wheelchair to her bed. R3 stated the injury to her right leg was on 11/25/24. R3 stated one of the female CRCA O had a German acescent and short blonde hair. R3 stated the male CRCA N is the one that usually transferred her with another person. R3 stated she had sat in her wheelchair for a while, so she knew it would take a minute or two once she started the transfer. Both CRCA's started helping her to transfer to bed from the wheelchair using a walker and R3 told them to wait a minute, wait a minute, her right leg was caught under the chair. CRCA O told her to come on, keep going. R3 stated again wait a minute, wait a minute, my right leg was caught under the chair, and again CRCA O told R3 to keep going. R3 stated that CRCA O told her to grab the rail on her bed so they could transfer her up on the bed. R3 stated she was sitting at the edge of the wheelchair by this time, and again asked them to wait a minute and they did not. Both CRCA's N and O continued moving her over to the bed. R3 stated they continued with transfer and CRCA N purposefully pushed her the rest of the way on the bed and R3 stated she could feel right leg crack. R3 told CRCA N that she hurt her right leg and was tearful due to the right leg pain. R3 stated she told CRCA O that she needed something for pain, and CRCA O told R3 she would go tell the nurse. R3 stated that the nurse came into her room to give her some pain medication. R3's family member P requested an x-ray be done to the right leg as it hurt more than usual. R3 stated whenever her right leg was moved, it hurt. Record review revealed R3 had a portable x-ray at the facility on 11/25/24 following the incident and the results did not show the fracture. Record review revealed R3 was sent out to the local emergency room after family member P insisted on 12/03/24 for increased right leg pain. The emergency evaluation was not initiated based on the facility staff assessment. The evaluation was upon the instance of R3s famly member P. The hospital x-ray report documentation from the emergency room evaluation revealed R3 had a closed fracture of proximal end of right tibia, unspecified fracture morphology. R3 returned to the facility with discharge instruction to follow up with Orthopedic Trauma. During an interview on 01/28/25 at 1:10 PM, family member P voiced concern that CRCA N and O broke R3's leg, they kept pulling on her, and they didn't stop. Family member P stated that it took the facility a couple days, before they sent her to the hospital, and did so when she insisted, causing a delay in treatment. Family member P was told R3's pain was due to arthritis, joint arthritis, but hospital discharge paperwork reported she had a fracture in her right leg. Family member P stated the hospital x-rayed her leg, put her in a brace/immobilizer and told R3, to not take it off until she sees an orthopedic trauma specialist. Family member P stated, she called and scheduled the first appointment, but the facility rescheduled, due to not having transportation to get R3 there. Family member P stated R3 went to the next appointment and the physician reported they saw the fracture and would monitor it. Family member P stated the hospital discharge paperwork stated R3 had osteoarthritis and a fracture like this, would come from a forceful pull. Family member P stated R3 had to keep the immobilizer on for approximately 4 to 6 weeks. Family member P stated R3 was finally able to take the brace/immobilizer off and started back up with physical therapy. R3 will have a follow up appointment with orthopedic trauma specialist in the near future, and she will call and find out the date and time. R3 could walk before all this and now this will put her behind now. There was a delay in treatment from the facility, as they did not respond timely following the incident. R3 continued to complaint of increased pain in the right leg without sending her to the hospital until family member P insisted. Record review on 01/28/25 11:18 AM, revealed a final investigation reporting of this incident from the facility Administrator to the State of Michigan in a Facility Reported Incident (FRI). Record review of the FRI included staff interviews with the following. 1) CRCA O interviewed on 12/04/24, she was helping to transfer, R3 was in a wheelchair, and they were trying to transfer to the bed with the rolling walker. After they transferred her to bed, R3 complained of pain in her leg, and she notified the nurse. 2) CRCA N interviewed on 12/04/24, they entered R3's room because she wanted to get into bed. R3 was a 2 person transfer from the wheelchair with a walker. CRCA N stated he put the walker in front of R3 and the other CRCA was on either side of her for support. R3 stood up and they helped pivot her to bed. CRCA N stated it was a typical transfer for resident, and nothing went different from any other transfer. CRCA N stated that R3 did state that her legs hurt one more than the other and asked for pain medication. CRCA N stated he went and told the nurse pain meds were needed. 3) CRCA Q interviewed on 12/04/24, R3 did not assist with any transfers, accept when resident was sent out to the local hospital emergency roiagnom on [DATE]. 4) RN R interviewed on 12/04/24, R3 complained of pain, family member P requested R3 to be sent out to local hospital emergency room . No marks or increased pain noted prior to being sent out to the hospital. RN R stated R3told her that it occurred during a transfer. 5) Afternoon RN Supervisor S interviewed on 12/09/24, CRCA approached him around 9:00 PM, stating R3 wanted a pain pill. He pulled the medication out for resident, went to room where family stated they wanted an x-ray of her left leg. Family stated the right leg hurt more than usual. Resident also stated abdomen always hurts. He called the on-call provider and explained concerns also noting the R3 leg was not red, warm or swollen, when compared to the other leg and baseline. on call stated it could be arthritic in nature or a DVT and notified rounding provider. Family notified and rounding provider ordered x-rays. 6) CRCA N interviewed on 12/04/24, They entered the resident's room because she wanted to get into bed. She is a 2 person transfer with a walker, put walker in front of R3 and each one of us on either side of her for support. She stood up and they helped pivot her to bed. It was a typical transfer for resident, and nothing went different from any other transfer. Resident did state that her legs hurt one more than the other and asked for pain medication. Told the nurse pain meds were needed. 7) R3's roommate T interviewed on 12/04/24, CRCA O helped with transfer on R3, was in wheelchair and they transferred R3, and she complained of pain in legs, and they notified nurse. During record review on 01/28/25 at 1:54 PM, writer noted that there was no interview with R3 in the investigation. Writer requested the interview between R3 and Executive Director/ LNA A. After receiving this Statement of Witness Form sometime later, the interview form was typed not written, there was no signature by R3 nor was it dated. Those 2 areas were left blank. The Executive Director/LNA A and Assistant Director of Health Services signed and dated this form. Record review of hospital after visit summary dated 12/3/24. Documented reason for visit- knee pain. Diagnosis- Closed fracture of proximal end of the right tibia, unspecified fracture morphology, initial encounter. XR Knee Right 3 views. Findings- Nondisplaced fracture involving the proximal tibia diaphysis extending to tibial compartment of the arthropathy. Articular surfaces and joint spaces: Total knee arthroplasty is intact. Bones: Well, mineralized without lytic or sclerotic process. No evidence of suprapatellar effusion. Lower extremity edema. Impression: Nondisplaced fracture involving the proximal tibia diaphysis extending to tibial compartment of the arthroplasty. Correlation with CT may be useful. Record review of R3's interview on the injury of unknown origin was dated 12/04/24. The content of the interview was conducted with Executive Director/LNA A and Assistant Director of Health Services U met with R3 and family member P on 12/04/24, both stated the fracture occurred while 2 CRCA's N and O were transferring her. Family member P stated it is not an injury of unknown origin, we know how it happened, during her transfer, when R3 told them to stop and they didn't. During an interview on 01/29/25 10:10 AM, R3 stated the Executive Director/LNA A came back in to interview her without her family member P present. R3 stated she came in and asked a few questions, R3 stated she gave them details of what happened again. During an interview on 01/29/25 at 11:30 AM, Cognitively intact R3 stated that prior to the fracture of her right leg, she could walk with assistance using her walker from the bed to the door, around her room. R3 then stated that now, she can no longer walk with assistance and her walker, she had to use a mechanical lift to transfer with 2-3 people. R3 stated she required more pain medication after the fracture, because it hurt to have her leg moved. R3 had a change in her mobility status from using a walker with assistance to using a mechanical lift with 2-3 people due to being non-weight bearing. R3 also stated that this was a little depressing to her, as she was already being treated for depression. It had affected her psychological status as well. During an interview on 01/29/25 at 12:23 PM, Minimum Data Set (MDS) Nurse C stated she did the December 2024 MDS Assessment. MDS Nurse C stated R3 was up with 2 persons assist and walker, no other devices. MDS Nurse C stated that she completed the December's assessment, and she was downgraded to a mechanical lift, she is non-ambulatory, non-weight bearing, dependent on transfers from chair to bed, all transfers became dependent. During an interview on 01/29/25 at 12:55 PM, Physical Therapy Director (PTD) stated R3 was a 2 person assist with walker and a gait belt, and now a mechanical lift because she is non-weight bearing on her leg. PTD V stated Occupational Therapy (OT) was working on upper body exercises, Activities of Daily Living (ADL), overall weakness, more now than before. PTD V stated Physical Therapy (PT) was working on range of motion on leg, seat to balance bed mobility, core strengthening. R3 assist with upper body dressing, upper body exercises, she does well. During an interview on 01/29/25 at 1:03 PM, family member P Stated R3 called her about the injury right after it happened, so she came right up. Family member P stated ED/LNA A and ADHS U came up to R3's room [ROOM NUMBER] times with her there, then again without her there. Family Member P stated they were upsetting R3 with all the questions that she had already answered. ED/LNA A and ADHS U asked R3 again what happened the day of her right leg injury, she gave the same details again, asked R3 if she was sure, it was this person or not. Family Member P stated the second time they asked the same questions and tried to turn it around. Family member P stated they didn't want to give R3 pain medications, didn't know why. R3 did have increased pain from this incident. Family member P stated R3 didn't have the pain in her right leg, that she does now. During an interview on 01/29/25 at 1:18 PM, CRCA O stated she had helped to take care of R3. CRCA O stated she was now a total lift, she positioned her, checked and changed her and that was it. CRCA O stated sometimes they need 3 people. CRCA O stated she helped transfer R3 once, helped CRCA N with transferring, she was 2nd person assist on 2nd shift. R3 was sleeping in her wheelchair, she was too extensive, positioned chair up to bed, helped her stand up, using the walker in front of her, waiting for her to move her feet to sit on bed, R3 was not moving just standing there. CRCA O stated she asked her to move to her bed. CRCA N was on the right side, and she was on the left side of the chair. CRCA O stated she didn't remember being told to wait a minute by R3. CRCA O was told R3 needed a pain pill. CRCA O stated that R3 told her, that she broke her leg. During an interview on 01/29/25 at 1:28 PM, CRCA N stated he was one of the CRCA O on the side of the chair, he was in the back. CRCA N stated R3 was a 2-person transfer, R3 was standing there, then got her to bed, then checked and changed her and got her positioned her in bed. CRCA N stated he did not recall if R3 told them to wait a minute, wait a minute. Record review of the FRI investigation of the incident on 11/25/2024, revealed transfer training was provided to staff through the therapy department, and a sign in sheet was provided. It revealed that abuse education had been provided, but there was not a separate sign in sheet for that training, not knowing who did or did not attend. This document was not part of the FRI- submitted to the State of Michigan. Writer requested the missing information at 01/29/25 at 1:45 PM, via email to Executive Director/LNA A. Missing information was later provided. 46954 Resident #4 (R4) Review of the medical record reflected R4 was admitted to the facility on [DATE], with diagnoses that included wedge compression fracture of first lumbar vertebra and chronic pain. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/02/2024, reflected R4 scored 14 out of 15 (cognitively intact ) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of a Progress Note dated 12/11/2024 at 2:52 PM, R4 was noted to have two upcoming appointments for R4 with a pain clinic. 1. 1/8/25 @ 10:15 am and 2. 1/22/25 @ 10:45 am . Review of Progress note dated 01/08/2025 at 08:41 AM reflected Residents (R4) appointment on 1/8/25 was rescheduled for 1/13/24 with [redacted] pain clinic. Nurse was notified and there was a difficulty with transport on the 8th. Review of a Progress Note dated 1/09/2025 at 1:18 PM stated Cancelled residents (R4) appointment with [redacted] pain clinic on Monday, 1/13/25. The (facility) bus is being serviced and we can;t provide transport. Will reschedule when vehilce [sic] is back. Review of a Progress Note dated 1/21/2025 at 10:45 AM stated Residents (R4) appointment on 1/22/25 was cancelled with [redacted] pain clinic. No transportation is available due to bus in shop. Will reschedule when bus is available. In an interview on 01/29/25 at 11:49 AM, Life Enrichment (LE) E stated that she is the primary driver of the facility vehicle and also assists with the scheduling of appointments for residents. LE E stated for the past few months, the facility vehicle has been in the shop a lot however, more recently, the facility vehicle has been completely out of commission for about three weeks. In the meantime the facility has been encouraging families to provide transportation and/or hire outside transportation to assist with the residents getting to and from outside appointments. LE E stated that the facility had had to reschedule R4's pain clinic appointments due to the facility vehicle being out of commission, however, was unsure why an outside transportation company was not consulted to assist with transporting R4 to her appointments. LE E confirmed that the last pain clinic appointment R4 had attended was on 11/15/24. On 1/29/25 at 12:59 PM, R4 was observed in her room self propelling toward her dresser. When asked about the pain clinic, R4 stated that she had been attending the pain clinic for pain injections for months. R4 stated that she had a chronic back pain problem and that she doesn't like taking pills so she elected to attend the pain clinic to assist in pain relief. R4 stated that she felt that she was ready for her next injection and that her back pain was coming back because she had been requesting more of her as needed Tylenol lately. R4 stated that she felt more than ready for her next injection and was not aware of her pain clinic appointments being cancelled and rescheduled due to lack of transportation.

Based on observation, interview and record review, the facility failed to ensure timely ophthalmology services for one (Resident #49) of one reviewed for vision, resulting in lack of timely eye care services and the missed treatments. Findings include: Resident #49 (R49) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R49 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included type 2 diabetes mellitus with unspecified diabetic retinopathy, hypertension (high blood pressure), chronic kidney disease, and depression. The MDS reflected R49 had a BIM (assessment tool) score of 12 which indicated his ability to make daily decisions was moderately impaired. During an observation and interview on 1/27/25 at 12:33 PM, R49 was sitting at table in dining room with another resident. R49 reported appeared pleasant and able to answer questions without difficulty. R49 reported concern related to facility bus was not functioning and had missed two to three eye appointments including for eye injections in past two weeks. R49 reported was upset because eye doctor told him he could go blind if treatment plan was not completed. R49 and other resident reported facility bus had not been available for outings for months. During an observation and record review on 1/28/25 at 9:15 AM, Daily Chronicle was posted near main dining room and outside Nursing Home Administrator office, dated 1/28/25. The posting included activity calendar information, The OUTINGS will be announced when we have our bus back from maintenance, Thank You for your patience and support with this matter. Review of the facility, Daily Chronicle, dated 1/14/25 through 1/28/25, reflected, TODAY'S OUTING: Cancelled while the bus is being serviced. Review of R49 Nursing Progress Notes, dated 11/25/2024 at 2:37 p.m., reflected, Pt has a f/u[follow up] with a retina specialist on 12-6-24. at [named ophthalmology]. Review of R49 Progress Notes, dated 12/23/2024, reflected, Resident has 3 upcoming Appointments with [named ophthalmology office] . 1. 1/22/25 @ 2:25 pm p/u 1:45 pm 2. 2/26/25 @ 10:10 am p/u 9:30 am 3. 3/27.25 @ 10:10 am p/u 9:30 am Review of R49 Nursing Progress Notes, dated 1/09/2025 at 1:42 PM, reflected, [Named facility] bus is not working unexpectedly , will need to set up Transportation for tomorrow's outpatient procedure . Transportation options include-[five named transportation options with numbers] During a telephone interview on 1/29/25 at 11:15 AM, R49's ophthalmology office reported R49 last appointment was 12/23/24 with eye injections scheduled for 1/22/25 that was rescheduled to 2/13/25, then 2/26/25, and 3/27/25. During a telephone interview on 1/29/25 at 11:25 AM, R49's guardian office staff W reported guardian had no knowledge of R49's 12/23/24 eye appointment. Guardian office W reported last known appointment was 11/25/24. Guardian office W verified no knowledge of planned follow up appointments reported usually facility communicates with guardian office they sends representative to appointment and if not they follow up with consulting provider. During an interview on 1/29/25 at 11:49 AM, Activities/Transportation(AT) staff E reported was also transportation driver for facility outings on Tuesdays and Thursdays. AT E reported facility bus has been having maintenance issues since September 2024 and was no longer drivable and facility had loner vehicle that also had maintenance issues and not working for at least 3 weeks. AT E reported attempt to get families involved to transport residents and if not reschedule appointments or hire outside transportation. AT E reported R49 eye appointments have had to be rescheduled related to no transportation. AT E reported was present at R49 eye appointment on 12/23/24 and R49 received eye injection that was part of series of injections with appointments that included 1/22/25 that had to be rescheduled because of no transportation. AT E reported was unsure why outside transportation was not arranged but nursing staff was responsible for that. Review of the R49 Electronic Medical Record, dated 11/25/24 through 1/29/25, reflected no evidence of R49 Ophthalmology appointments consult notes for 11/15/24 or 12/23/24. During a telephone interview on 1/29/25 at 12:22 PM, R49's ophthalmology office staff reported R49 was seen 11/25/24 and 12/23/24 in office and 12/6/25 appointment was canceled because R49 did not have guardian or facility staff present at office with R49. Review of R49's Ophthalmology Consult, dated 11/25/24, reflected, The [AGE] year old patient presents for evaluation of Dm[diabetes mellitus] in the right eye and left eye .Said within the last one year vision has deteriorated a lot. Trouble with small print, recognizing people, hazy blurry vision and seeing in dim light OU[both eyes]. Diabetic since 2007 .The patient is present for evaluation of Cataracts in the right eye and left eye .Plan-Cataract OU[both eyes]- Visually significant. Pt with decreased acuity and glare, affecting activities of daily living .Pt will need to be evaluated by Retina for diabetic retinopathy and possible injections before surgery .DM/NPDR[diabetic mellitus/nonproliferative diabetic retinopathy] OU- Severe NPDR OD[right eye]/Moderate OS[left eye]. Will refer for retina consult before scheduling cataract surgery. Advised patient he may need injections. After retina consult will move forward with cataract surgery depending on treatment plan . Review of R49's Ophthalmology Retinal Consult, dated 12/23/24, reflected, Plan .Discussed with patient there is significant damage to the inside of the eyes from the diabetes. In order to reduce swelling and preserve vision [named physician] recommends monthly treatments with Avastin. Will plan for [NAME][intravitreal injection] OU today and 2 automatic injections at 1 month intervals. Will reevaluate plan of care in 3 months .Cataracts OU - Okay to move forward with cataract surgery as long as patient continues treatment. Patient will need injections 1-2 weeks prior to surgery . During an interview on 1/29/25 at 1:40 PM, Registered Nurse(RN) J reported outside consult visits process that included when residents returned from consult staff obtain consult follow up documents from resident or call office and document in progress notes. Nurse X was present during interview and reported R49 eye appointment last week was canceled related to transportation. Nurse X or RN J reported were unsure why other transportation options were not utilized. During an interview on 1/29/25 at 1:59 PM, Director of Nursing(DON) B reported nursing staff expected to ask residents for post consult visit notes, the nurse communicates with physician, and documents in progress notes. DON B reported nursing staff expected to follow up with Consulted Physician if residents does not provide documentation within 24 hours. During an interview on 1/29/25 at 2:47 PM, DON B verified no notes in EMR to reflect R49 missed appointment 1/22/25 and no visit notes in EMR for 11/25/24 or 12/23/24 and have contacted [named Ophthalmology office] for consult visit notes for recent visits.

Based on observation, interview and record review, the facility failed to maintain complete and accurate medical records for two (R7, R49) of 17 residents reviewed for medical records. Findings include: Resident # 7 (R7) Review of the Narcotic Record binder, on 1/28/25 at 11:19 a.m., located on the 100 hall medication cart, revealed, R7 had, Controlled Drug Use Record for Norco 10/325 mg 1 tablet, Xanax 0.25mg 1 tablet, and Tramadol 50mg 1/2 tablet all documented as given at 11:00 a.m. Review of the 100 hall medication cart and interview on 1/28/25 at 11:22 AM, Registered Nurse (RN) K unlocked 100 hall medication cart, revealed a unlabeled medication cup with at least 2 unidentified pills in the top drawer. RN K grabbed the cup of medications and reported was resident 11:00 am medications and needed to administer medications now, locked medication cart and entered R7. This surveyor heard RN K tell R7 she had her Norco and Tramadol(Controled narcotics). RN K returned to the medication cart and opened the cart. During an interview on 1/28/25 about 3:40 PM, DON B reported would expect nurses to document at the time medication was administered. Resident #49 (R49) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R49 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included type 2 diabetes mellitus with unspecified diabetic retinopathy, hypertension (high blood pressure), chronic kidney disease, and depression. The MDS reflected R49 had a BIM (assessment tool) score of 12 which indicated his ability to make daily decisions was moderately impaired. During an observation and interview on 1/27/25 at 12:33 PM, R49 was sitting at table in dining room with another resident. R49 appeared pleasant and able to answer questions without difficulty. R49 reported concern related to facility bus was not functioning and had missed two to three eye appointments including for eye injections in past two weeks. R49 reported was upset because eye doctor told him he could go blind if treatment plan was not completed. Review of R49 Nursing Progress Notes, dated 11/25/2024 at 2:37 p.m., reflected, Pt has a f/u[follow up] with a retina specialist on 12-6-24. at [named ophthalmology]. Review of R49 Progress Notes, dated 12/23/2024, reflected, Resident has 3 upcoming Appointments with [named ophthalmology office] . 1. 1/22/25 @ 2:25 pm p/u 1:45 pm 2. 2/26/25 @ 10:10 am p/u 9:30 am 3. 3/27.25 @ 10:10 am p/u 9:30 am During a telephone interview on 1/29/25 at 11:15 AM, R49's ophthalmology office reported R49 last appointment was 12/23/24 with eye injections scheduled for 1/22/25 that was rescheduled to 2/13/25, then 2/26/25, and 3/27/25. During a telephone interview on 1/29/25 at 11:25 AM, R49's guardian office staff W reported guardian had no knowledge of R49's 12/23/24 eye appointment. Guardian office W reported last known appointment was 11/25/24. Guardian office W verified no knowledge of planned follow up appointments reported usually facility communicates with guardian office they sends representative to appointment and if not they follow up with consulting provider. During an interview on 1/29/25 at 11:49 AM, Activities/Transportation(AT) staff E reported R49 eye appointments have had to be rescheduled related to no transportation. AT E reported was present at R49 eye appointment on 12/23/24 and R49 received eye injection that was part of series of injections with appointments that included 1/22/25 that had to be rescheduled because of no transportation. AT E reported nurse were responsible for obtaining consult visit notes and if not provided on day of visit. Review of the R49 Electronic Medical Record, dated 11/25/24 through 1/29/25, reflected no evidence of R49 Ophthalmology appointments consult notes for 11/15/24 or 12/23/24. During a telephone interview on 1/29/25 at 12:22 PM, R49's ophthalmology office staff reported R49 was seen 11/25/24 and 12/23/24 in office and 12/6/25 appointment was canceled because R49 did not have guardian or facility staff present at office with R49. Review of R49's Ophthalmology Consult, dated 11/25/24, reflected, The [AGE] year old patient presents for evaluation of Dm[diabetes mellitus] in the right eye and left eye .Said within the last one year vision has deteriorated a lot. Trouble with small print, recognizing people, hazy blurry vision and seeing in dim light OU[both eyes]. Diabetic since 2007 .The patient is present for evaluation of Cataracts in the right eye and left eye .Plan-Cataract OU[both eyes]- Visually significant. Pt with decreased acuity and glare, affecting activities of daily living .Pt will need to be evaluated by Retina for diabetic retinopathy and possible injections before surgery .DM/NPDR[diabetic mellitus/nonproliferative diabetic retinopathy] OU- Severe NPDR OD[right eye]/Moderate OS[left eye]. Will refer for retina consult before scheduling cataract surgery. Advised patient he may need injections. After retina consult will move forward with cataract surgery depending on treatment plan . Review of R49's Ophthalmology Retinal Consult, dated 12/23/24, reflected, Plan .Discussed with patient there is significant damage to the inside of the eyes from the diabetes. In order to reduce swelling and preserve vision [named physician] recommends monthly treatments with Avastin. Will plan for [NAME][intravitreal injection] OU today and 2 automatic injections at 1 month intervals. Will reevaluate plan of care in 3 months .Cataracts OU - Okay to move forward with cataract surgery as long as patient continues treatment. Patient will need injections 1-2 weeks prior to surgery . During an interview on 1/29/25 at 1:40 PM, Registered Nurse(RN) J reported outside consult visits process that included when residents returned from consult staff obtain consult follow up documents from resident or call office and document in progress notes. Nurse X was present during interview and reported R49 eye appointment last week was canceled related to transportation. During an interview on 1/29/25 at 1:59 PM, Director of Nursing(DON) B reported nursing staff expected to ask residents for post consult visit notes, the nurse communicates with physician, and documents in progress notes. DON B reported nursing staff expected to follow up with Consulted Physician if residents does not provide documentation within 24 hours. During an interview on 1/29/25 at 2:47 PM, DON B verified no notes in EMR to reflect R49 missed appointment 1/22/25 and no visit notes in EMR for 11/25/24 or 12/23/24 and planned to contacted [named Ophthalmology office] for consult visit notes for recent visits.

This citation pertains to intake number MI00146626. Based on observation, interview and record review the facility failed to ensure one out of three residents (Resident #1) Physician's orders and treatment were correct and documented. Findings Included: Per the facility face sheet Resident #1 (R1) was admitted to the facility on [DATE] with a diagnosis of diabetes. Review of R1's Hospice records revealed R1 was admitted to Hospice on 8/8/2024. Review of Physician's orders dated 8/14/2024, revealed R1 was made a no code (DNR). Review of R1's medication administration record (MAR) for the month of August 2024 revealed R1 was to have her blood sugar level checked before each meal and at bedtime. The MAR revealed a scale was ordered for the amount of insulin R1 was to receive such as, if R1's blood sugar level was anywhere between 151-200 R1 was to receive 3 units of Humalog insulin, and so forth. Further review of the MAR revealed that on 8/26/2024 at the R1's bedtime check her blood sugar level was 60, on 8/27/2024 before R1's breakfast her blood sugar level was 65, and before R1's lunch her blood sugar level was 47. There were no further blood sugar checks documented for R1 on 8/27/2024. Review of R1's progress notes dated 8/25/2024, revealed that Registered Nurse (RN) C notified the Physician and received an order to administer Glocagon 1 mg. RN C then rechecked R1's blood sugar at 2:16 AM, and documented R1 was alert with no signs of distress. There was no nursing documentation in R1's progress notes regarding the 6/27/2024 before breakfast blood sugar level of 65. There was no nursing documentation in R1's progress notes regarding the 6/27/2024 before lunch blood sugar level of 47. In an interview on 8/30/2024 at 12:00 PM, Registered Nurse (RN) D stated that it was Tuesday the 27th of August on her 6:00 AM-2:00 PM shift. RN D said she received report and was told R1 was not doing well. RN D said she had seen R1 first, and said R1's blood sugar was 68. RN D stated she had checked R1's blood sugar again about an hour later and R1's level at that time was 65. RN D said R1 was progressing downward, and had been more lethargic (sleepy) for the past few days. RN D said she had taken R1's accu check at lunch time on 8/27/2024 which was 47. RN D said she went to the Nurse Practitioner (NP) E who was onsite and told her about the 47 level. RN D said NP E told her to discontinue the accuchecks on R1. Another review of R1's progress notes revealed no documentation by RN D regarding reporting R1's blood sugar level of 47 nor receiving orders to discontinue accuchecks. In an interview on 8/30/2024 at 11:11 AM, NP E stated that she was made aware about R1's breakfast level on 8/27/2024 of 60. NP E said she went in and saw R1 and said R1 was alert. NP E said she asked the nurses to give R1 OJ and crackers E said she was not told about R1's lunch time blood sugar level of 47, and stated that she would expect that low of a level she would have been notified. NP E said she did not discontinue the accucheck but rather told the nurse to do them as needed and not routinely. NP E stated that was why she put into place glucose order PRN (as needed) accuchecks and glucose orders, one for if R1 was responsive and one if R1 was not responsive. Review of Physician's orders dated 8/27/2024, revealed an order if R1's blood sugar was < (less than) 50 and she was alert, Give 30-gram carbohydrate oral feeding of one of the following: 2 tubes of glucose gel, or 8 ounces of any juice without added sugar, or 8 ounces of regular soda pop. Special Instructions: Recheck BS (blood sugar) in 15 mins (minutes) if BS < 70, repeat 15 gram carbohydrate. Ordered to be done four time a day as needed. The other order dated 8/27/2024, revealed if R1's blood sugar was 50-69 then nursing was to give her 15 gram of carbohydrate via either 1 tube of glucose gel, or 4 ounces of any juice without added sugar, or 4 ounces of regular soda pop, or 8 ounces of low-fat/nonfat milk. The order was to be done four times a day as needed. Another order in place and dated 8/27/2024, revealed if R1's bloods sugar level was <50 and she was unresponsive/unable to swallow nursing was to administer 1 mg of glucose intranasally, and if R1 did not respond after 15 minutes the give a second dose and call emergency assistance. The order was for twice a day as needed. Review of R1's MAR for the month of August 2024 revealed the three above orders were not available to nursing to administer to R1 per the X in each signature box. Further review of R1's August MAR revealed no order was written for PRN accuchecks as NP E stated. In an interview on 8/30/2024 at 2:10 PM, RN C stated he was told by RN D, who he received report from, that NP E said to no longer monitor R1's blood sugar levels and to no longer administer Glucagon. RN C said RN D reported to him that R1's last blood sugar was 56. RN C said R1 was lethargic and he thought it was because her blood sugar was low. RN C said he did not confirm by looking at R1's Physician orders if R1's accuchecks and glucose were confirmed to be discontinued. Record review of an, Observation Detail List Report dated 8/27/2024, revealed R1 was transferred to the hospital on 8/27/2024. Review of R1's progress notes for the date of 8/27/2024 revealed that R1 was transferred to the hospital per family request at 9:45 PM. There was no documentation of the reason R1 required a transfer to the hospital, there was no documentation of the status of R1's condition at the time nor prior to her transfer to the hospital. Furthermore, there was no documentation in the progress notes nor the MAR of R1 having a blood sugar level of 68 or 56 as reported by RN D.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 59 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination. Findings include: On 01/03/24 at 09:05 A.M., An interview was conducted with Director of Plant Operations C regarding the facility maintenance work order system. Director of Plant Operations C stated: We have the Direct Supply TELS software system for entering and monitoring maintenance work orders. On 01/03/24 at 01:15 P.M., An environmental tour of sampled resident rooms was conducted with Director of Environmental Services D. The following items were noted: 101: The drywall surface was observed (etched, scored, particulate), adjacent to the restroom entrance door. The damaged drywall surface measured approximately 2.5-feet-wide by 3-feet-high. 105: The Bed 2 drywall surface was observed (etched, scored, particulate), directly behind the motorized reclining chair. The damaged drywall surface measured approximately 3-feet-wide by 3-feet-high. The restroom return-air-exhaust ventilation grill was also observed soiled with accumulated dust and dirt deposits. 106: The restroom return-air-exhaust ventilation grill was observed soiled with accumulated dust and dirt deposits. 111: The overbed light assembly upper 48-inch-long fluorescent bulb was observed non-functional. Director of Environmental Services D indicated she would have maintenance replace the faulty bulb as soon as possible. 203: The restroom return-air-exhaust ventilation grill was observed soiled with accumulated dust and dirt deposits. 215: The wall mounted Packaged Terminal Air Conditioning (PTAC) Unit filters were observed soiled with accumulated dust and dirt deposits. Director of Environmental Services D indicated she would have her staff thoroughly clean the unit filters as soon as possible. 217: The pull string extension was observed missing on the overbed light assembly. The restroom return-air-exhaust ventilation grill was also observed soiled with accumulated dust and dirt deposits. The bedside cabinet doorstop assembly was additionally observed broken, allowing the door to protrude into the interior cabinetry space. 304: The Bed 2 overbed light assembly was observed with a broken actuation switch. The pull string extension was also observed missing. The restroom return-air-exhaust ventilation grill was further observed soiled with accumulated dust and dirt deposits. The wall mounted (PTAC) Unit filters were additionally observed soiled with accumulated dust and dirt deposits. 409: The overhead light assembly pull string extension was observed missing. On 01/04/24 at 10:00 A.M., Record review of the Policy/Procedure entitled: Room Cleaning-Health Center Rooms dated 6-15-2022 revealed under Policy: Health Center resident rooms are cleaned daily and deep cleaned monthly. Record review of the Policy/Procedure entitled: Room Cleaning-Health Center Rooms dated 6-15-2022 further revealed under Procedures: Monthly Deep Cleaning - Pull PTAC filter and vacuum. On 01/04/24 at 10:15 A.M., Record review of the Policy/Procedure entitled: Preventative Maintenance Procedures dated 2/06/2018 revealed under Policy: Preventative Maintenance is an integral part of the Director of Plant Operations duties. Each piece of equipment or section of the building has its own inspection schedule and procedures to follow to prolong the life expectancy of the equipment and decrease the chances of equipment failure. On 01/04/2024 at 10:30 A.M., Record review of the Direct Supply TELS Work Orders for the last 60 days revealed no specific entries related to the aforementioned maintenance concerns.

Based on observation, interview and record review, the facility failed to develop a comprehensive care plan for one (Resident #22) of 15 reviewed for care plans, resulting in the potential for unmet care needs. Review of the medical record reflected Resident #22 (R22) admitted to the facility on [DATE], with diagnoses that included pulmonary embolism (blood clot in the lung), pulmonary fibrosis (damaged and scarred lung tissue), pneumonia and chronic obstructive pulmonary disease (COPD). The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/18/23, reflected R22 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was coded for oxygen use and frequent bowel and bladder incontinence. The MDS completion date was 12/26/23. On 01/02/24 at 04:00 PM, R22 was observed seated in her room, in a wheelchair, with oxygen via nasal cannula in place. R22 reported she had a blood clot in her lung prior to facility admission and a history of pneumonia. R22 reported she used Oxytrol patches (for overactive bladder), that her family supplied. R22 reported that without the patches, she may have to urinate every hour. R22's medical record was not reflective of care plans pertaining to bowel and/or bladder incontinence or her respiratory diagnoses and interventions. During an interview on 01/04/24 at 12:55 PM, MDS Support Registered Nurse (RN) L and MDS RN M reported the comprehensive care plan was done when doing the comprehensive MDS assessment (such as admission MDS). It was reported that the comprehensive care plan had to be completed by day 21 or seven days after the completion date of the comprehensive MDS assessment. It was reported that R22 had a comprehensive care plan in place at the time of the interview. Additionally, it was reported that R22 should have had a care plan pertaining to incontinence, as well as a respiratory care plan, as based off the Progress Notes, R22 appeared to still be having respiratory symptoms.

Based on observation, interview and record review, the facility failed to ensure timely assessment and follow-up for a change in condition for one (Resident #22) of 15 reviewed, resulting in the potential for delayed identification of changes in condition and delay in treatment. Findings include: Review of the medical record reflected Resident #22 (R22) admitted to the facility on [DATE], with diagnoses that included pulmonary embolism (blood clot in the lung), pulmonary fibrosis (damaged and scarred lung tissue), pneumonia and chronic obstructive pulmonary disease (COPD). The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/18/23, reflected R22 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was coded for oxygen use and frequent bowel and bladder incontinence. A Physician's Order with a start date of 12/13/23 and a discontinue date of 12/27/23 reflected R22 had a previous order for two liters of oxygen per minute, via nasal cannula, as needed at bedtime. On 01/02/24 at 04:00 PM, R22 was observed seated in her room, in a wheelchair, with oxygen via nasal cannula in place. R22 reported she had a blood clot in her lung prior to facility admission and a history of pneumonia. Towards the end of the observation and interview, R22 was noted to cough several times. She stated the cough developed two days prior, and the facility had given her an inhaler the previous day (1/1/24). R22 reported bringing up sputum with her cough, which she reported to the staff. According to R22, staff told her they may end up taking another x-ray but one had not been done, per her report. R22 denied that anyone had listened to her lung sounds since she began coughing. R22 reported she had also developed a runny nose. On 01/02/24 at 04:38 PM, Registered Nurse (RN) F stated a cough had not been reported to him, and this was his first day back to work in three days. RN F stated he had already been in and spoke with R22, and she had not mentioned a cough. RN F went to R22's room and could be overheard talking to her. A Progress Note for 01/02/2024 at 04:59 PM reflected R22 complained of a cough. The on-call provider was notified and ordered cough syrup every four hours, as needed, for three days. A Progress Note for 1/2/24 at 9:48 PM reflected R22's lung sounds were clear, and a cough was present with a small amount of sputum. On 01/03/24 at 03:30 PM, R22 was observed from the hallway to be in bed with the lights off. On 01/03/24 at 03:30 PM, RN F stated R22 had a cough that he had received an order for cough syrup for on 1/2/24. RN F stated the day shift nurse reported R22 was offered a chest x-ray but refused. He reported R22 had also been tested for Covid-19 the day prior (1/2/24) and was negative. On 01/04/24 at 09:42 AM, R22 was observed from the hallway, lying in bed, with the lights off. She was heard coughing. An oxygen concentrator could be heard in her room. On 01/04/24 at 10:09 AM, Director of Nursing (DON) B reported she had not heard about R22 having a cough, refusing a chest x-ray or being tested for Covid-19. During an interview on 01/04/24 at 10:14 AM, Licensed Practical Nurse (LPN) J reported R22 told her she had a cough. She asked R22 if she wanted a chest x-ray, but R22 stated she did not want one and only wanted cough syrup. LPN J stated respiratory assessments were being done for R22. She reported R22's respiratory rate was good and oxygen saturation levels were above 90%. LPN J stated she wanted to test R22 for Covid-19 that morning, but the midnight nurse stated she had already been tested and was negative. LPN J stated R22 had developed new chills, body pain and feeling feverish that morning (1/4/24), in addition to her cough. According to LPN J, R22 developed the cough on Sunday (12/31/23). She reported R22 had been coughing a lot on Sunday, but the cough was better with the cough syrup. During the same interview with LPN J, DON B approached and reported R22 now wanted a chest x-ray, after refusing it prior. LPN J reported it was not normal for R22 to still be in bed. She stated R22 liked to be up and in activities. Staff got R22 up in a chair that morning and had to put her back to bed, according to LPN J. LPN J reported R22 was the same on 1/4/24 as compared to 1/3/24. LPN J reported she had not been listening to R22's lung sounds. LPN J acknowledged that with a cough, such as R22's, she would typically listen to lung sounds. LPN J stated she had not had time to listen to R22's lung sounds. LPN J reported she did not listen to R22's lung sounds while on duty on 1/3/24 or 12/31/23. A Skilled Documentation Progress Note, authored by LPN J, for 1/3/24 at 2:42 PM reflected R22 had a cough with a small amount of sputum, and her lung sounds were clear. A Progress Note for 1/4/24 at 10:36 AM, authored by LPN J, reflected R22 had wheezing and crackles when listening to her lung sounds on both sides. A chest x-ray was ordered. The note reflected R22 refused prednisone for the cough. During an interview on 01/04/24 at 11:59 AM, Clinical Support RN K and DON B reported nurses were supposed to be doing head to toes assessments, including listening to lung sounds, for skilled charting. It was reported that the expectation for assessment included evaluating the cough, letting the provider know of any symptoms or additional symptoms, getting a chest x-ray, making a Progress Note, ensuring pain control, providing cough medicine, keeping the resident hydrated, checking their vital signs and making sure their oxygen saturation was above 90%. It was reported that lung sounds should have been assessed with skilled documentation. A Progress Note for 1/2/24 at 12:32 PM, which was a late entry note that was entered into R22's medical record on 1/4/24 at 1:34 PM, reflected R22 reported new onset of cough. A Covid-19 test was administered and was negative. A Progress Note for 1/3/24 at 1:25 PM, which was a late entry note that was entered into R22's medical record on 1/4/24 at 1:27 PM, reflected R22 was complaining of a cough. A chest x-ray was offered, and R22 refused. The note reflected R22 requested cough syrup, and orders were given for as needed cough syrup. According to the note, the Nurse Practitioner was notified and suggested prednisone (steroid medication) for the cough, which R22 refused. During an interview on 01/04/24 at 11:59 AM, Clinical Support RN K and DON B reported Covid-19 testing could be warranted with any respiratory issues, cough, shortness of breath or a high fever. It was reported that it was up to the discretion of the physician to decide if they wanted a resident retested for Covid-19. Review of R22's vital signs documentation on 1/4/24 at 2:06 PM reflected that her last documented oxygen saturation level was 90% on 1/4/24 at 6:51 AM. The value was flagged as an out of range finding. There was no documentation reflecting that R22's oxygen saturation had been reassessed. During an interview on 01/04/24 at 02:10 PM, DON B reported she spoke to the Nurse Practitioner, who reported being made aware, on 1/3/24, of R22's refusal of a chest x-ray and prednisone. She reported a STAT chest x-ray was ordered on 1/4/24, with the order request being faxed to the x-ray company at 1:39 PM on 1/4/24. DON B stated the company usually arrived within a couple of hours to obtain STAT x-rays. If the facility felt the x-ray was needed sooner, they could send the resident out. DON B reported the Nurse Practitioner saw R22 that same day (1/4/24). DON B reported R22 was negative for Covid-19 on 1/2/24. If she continued to have symptoms, was taking cough syrup and prednisone and not getting better after two to three days or had worsening symptoms, they could test again. DON B reported R22's admitting diagnosis was pneumonia, and she had no known Covid-19 exposure. According to the Progress Note for 1/4/24 at 10:36 AM, a chest x-ray was ordered for R22. A Radiology Order for a STAT chest x-ray was created on 1/4/24 at 1:39 PM (three hours later). As of 01/04/24 at 03:27 PM, R22's medical record did not reflect documentation of the Nurse Practitioner assessment for 1/4/24 and no indication that the STAT chest x-ray had been performed and results received by the facility.

Based on observation, interview, and record review the facility failed to post the actual daily Nursing Staffing Data resulting in the potential for all 59 Residents and/or family and/or visitors to be well informed of the facility's staffing information. Findings Included: During observation on 01/04/2024 at 03:21 p.m. the facility document entitled Todays Staffing was observed to be posted outside of the Director of Nursing Office, which was located at the beginning of the 200 hall. The Todays Staffing, dated 01/04/2024, listed the scheduled hours for all nursing staff but did not list any actual hours worked. The facility did not have actual hours worked for the previous date of 01/03/2024. In an interview on 01/04/2024 at 03:36 p.m. Nursing Schedular E explained that she post the scheduled nursing hours daily. She explained that she does not post the actual nursing hours used for the past shifts. In an interview on 01/04/2024 at 03:38 p.m. Nursing Home Administrator (NHA) A explained that the facility does not post the actual nursing hours used for the past shifts. She explained that the document posted, Todays Staffing, only included the scheduled nursing hours for that date.

This citation refers to Intake MI 592. Based on interview and record review, the facility failed to prevent a pressure wound for one sampled resident (#3) out of one resident reviewed for facility-acquired wounds resulting in R3 being sent to the hospital with a large, unstageable and infected pressure wound. Findings include: Resident #3 (R3) was admitted to the facility on [DATE] and discharged home on[DATE]. Her [DIAGNOSES REDACTED]. The fracture to the left fibula was being treated with a boot to the left foot. R3's Brief Interview for mental Status (BIMS) score was 15 out of a possible 15 points indicating this resident had no concerns with thinking and was her own person when making decisions. On 8/11/20, a record review of R3's electronic medical record (EMR) revealed the following information: a physician's orders [REDACTED]. There was no additional information with the order and it was written into the TAR (treatment administration record) as if the presence of the boot had to be visualized three times a day. On 7/7/20, a note was added to the Medication Administration Record [REDACTED]. There was no evidence in the EMR that an orthopedic physician had been contacted and there was no clarification of the initial order that the boot was to be opened so a skin assessment could be done. On 8/11/20 a record review of an intake received by the State Agency revealed the following information: On 7/28/20, a complaint was received from the local hospital that R3 had been admitted to the hospital and, when the boot to her left lower extremity was removed, R3 had a large infected and unstageable wound covered in black eschar to the sole of her foot and one of her toes looked black. R3 told the hospital staff that the facility did not remove the boot from her foot the entire time she was in the facility in spite of R3 complaining of pain in her toes. On 8/12/20, a record review of the policy titled Guidelines for Weekly Skin Observation, policy approval dates of 8/1/16 and 1/7/19, documented the purpose of the policy was to monitor the effectiveness of intervention for pressure reduction, identify areas of skin impairment in the early development stage and implement other preventative and/or treatment measures as indicated. Under the headline Procedure, item number 1 stated A full body observation shall be completed weekly by the licensed nurse. Item number 6 stated In addition to the Weekly observation by the licensed nurse, the nursing assistant shall observe the skin for areas of impairment with bathing and daily dressing and pericare and notify the nurse if an area is identified. On 8/12/20 at 10:30 AM, an interview with complainant (C) N occurred via the telephone. According to C N, R3 was discharged home on[DATE]. However, early on 7/26 at 4:00 AM, R3 woke up and complained of severe pain in her left foot. R3 was taken to the emergency room at a local hospital and, when the boot to her left foot was removed, it was discovered R3 had a large, infected, unstageable pressure wound to the sole of the foot. On 8/12/20 at 2:30 PM, MDS (Minimum Data Set) Registered Nurse (RN) F was interviewed. RN F wrote the initial and comprehensive care plans for the residents in the facility. When asked if R3 had any skin issues, RN F said No wounds that I'm aware of. On 8/12/20 at 3:00 PM, RN G was asked about foot care for diabetic residents. According to RN G, for a diabetic resident, it was very important to check a resident's feet if they have diabetes. You must remove a boot to check the skin. When asked if she removed R3's boot, she said there was no order to remove the boot. RN G stated no one checked with a physician to see why the staff couldn't remove R3's boot. On 8/12/20 at 3:30 PM, Certified Nursing Assistant (CENA) H was interviewed. CENA H stated she had cared for R3 and had never seen a nurse remove the boot from her left foot to check her skin. On 8/13/20 at 11:30 AM, in an interview with RN I, she stated that the admitting physician would be responsible for writing orders to remove the boot to check the skin on R3's left foot. On 8/13/20 at 1:15 PM, RN K was interviewed by phone. RN K stated she did not check R3's skin under her boot. On 8/13/20 at 4:30 PM, in an interview with Licensed Practical Nurse (LPN) L, she stated the facility policy stated the nurses should check the skin under R3's boot. On 8/14/20, a record review of the emergency room notes revealed, on 7/26/20, R3 had [DIAGNOSES REDACTED] (redness, a sign of infection) streaking up her left leg to mid-calf. Nurse Practitioner (NP) O documented, after assessing the wound,, the impression was that R3 had an unstageable pressure injury to the left foot and [MEDICAL CONDITION] (infection) to the left lower extremity. R3 was started on antibiotic therapy.

This citation pertains to intake MI 0429. Based on interview and record review the facility failed to: 1.) ensure the safety, 2.) implement care-planned and non-care-planned interventions, and 3.) ensure that those interventions were functional and in place in 1 of 4 sampled residents (Resident #1) reviewed for falls, resulting in Resident #1, who was dependant on staff for toileting, avoidable unwitnessed fall in the bathroom with head injury and pain and required transport to the hospital. Findings include: Resident #1(R1) Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected R1 was a [AGE] year old female admitted to the facility on [DATE], after several years in assisted living in same building, with [DIAGNOSES REDACTED]. The MDS reflected R1 had a BIM (assessment tool) score of 7 which indicated her ability to make daily decisions was severely impaired, and she required two person physical assist with bed mobility, transfers, dressing and toileting one person physical assist with locomotion on unit, hygiene, bathing and eating. During a telephone interview on 2/26/20 at 10:43 a.m. R1 family I reported R1 was admitted to the facility on [DATE], from the hospital, after a recent fall in the assisted living portion of the same building. R1's family I reported R1 was weak and required assistance with care including transfers. R1's family I reported the facility notified R1's family I that R1 had an unwitnessed fall on 1/30/20 in the bathroom, off the toilet. R1's family I reported R1 declined and hospice services were started on 2/10/20 and R1 passed away on 2/14/20. Review of the facility, Fall Event and investigation, dated 1/30/20 at 11:59 a.m., R1 had an unwitnessed fall in the bathroom after staff assisted transferred from the wheelchair to the toilet. The event reflected R1 was found on the floor with a bleeding laceration to right side of head with pain. The Event was completed by Director of Assisted Living(DAL) J. The investigation reflected Certified Nurse Assistant (CNA) L had assisted R1 to the bathroom on 1/30/20 just prior to the fall in the bathroom. CNA L had left R1 on the toilet in the bathroom alone while CNA L gather linens down the hall. CNA L witness statement reflected before CNA L returned to R1 room R1 had an unwitnessed fall on the floor in the bathroom. Review of the Admission Assessment, dated 1/29/20, reflected R1 was at risk for falls. Review of the Base Line Care Plans, dated 1/30/20 at 12:35 p.m., reflected R1 was at risk for falls(After R1 fall on 1/30/20. The Base Line Care Plans did not include fall interventions prior to 1/30/20. Review of the Fall Care Plan, dated 1/30/20, reflected no fall interventions for R1 prior to 1/30/20. Review of the CRCA Information Sheet, undated, located at the 300 hall nurse station, reflected R1 required two person assist with transfers and one to two person assist with toileting. The Information sheet reflected, Do NOT leave her alone in bathroom. The Information Sheet reflected R1 stated hospice services 2/11/20. During an interview on 2/26/20 at 4:02 p.m. Assisted Living Nurse (ALN) J reported the Director of Assisted Living (ALD) was K and reported management sometimes pulled him to work the floor in skilled nursing related to staffing needs. ALN J reported R1 records followed R1 from assisted living to skilled, including progress notes, care plans, and fall risks. During an interview on 2/26/20 at 4:45 p.m. Director of Nursing (DON) B reported the fall risk assessment was completed on admission and on the Base Line Care Plans. During an interview on 2/26/20 at 5:30 p.m. CNA M reported new admissions are evaluated by therapy services and staff follow recommendations. CNA M reported if new admission arrives after five o ' clock CNA M would talk with nurse and resident related to care needs including transfer status and reported would error on side of caution and provide more assistance if resident appeared really weak. CNA M reported therapy or nursing staff also add care needs to CRCA Information Sheets for each resident for staff to follow. Review of Hospital Discharge documents, dated 1/29/20, reflected R1 had a Physical Therapy Evaluation on 1/29/20 that reflected R1 was dependant with toileting and needed assistance with both static and dynamic sitting balance. During an interview on 2/27/20 at 9:06 a.m. Physical Therapist (PT) N reported working at the facility for five years. PT N reported residents that are new admissions or readmissions are evaluated by therapy same day or next day and review chart hospital records for resident status at time of hospital discharge. PT N reported she was very familiar with R1 as PT N also provided therapy services to R1 prior to Assisted Living discharge to hospital on [DATE]. PT N reported saw R1 on 1/30/20 for readmission evaluation after fall on 1/30/20 just before lunch. PT N reported R1 was in bed at the time with head wrapped. PT Nreported encouraged nurse staff to follow therapy notes from the hospital discharge documents if residents had not been seen for facility therapy evaluation for care needs and assistance. PT N reported that if hospital documents reflected, mod assist x 1 and staff determine resident might need more than PT N would recommend for staff to find additional help to assist because it would be safer for resident and staff. PT N stated, staff are able to downgrade assistance as much as needed but not upgrade. PT N reported prior to R1 transfer to the hospital status varied between mod assist and mod of 2. PT N reported after therapy evaluation was completed therapy department uses communication forms to nurse, DON, MDS nurse, and verbal communication to CNA staff after evaluation. PT N reported if residents are not modified independent resident should not be left alone in bathroom. PT N reported R1 fall on 1/30/20 could have been prevented. PT N reviewed R1 hospital PT records that reflected R1 needed min assist (1-25%) with sitting balance and dependant on staff assist with toileting. During an interview on 2/27/20 at 9:49 a.m. Physical Therapy Assistant (PTA) O reported working as the Program Director for one week. PTA O reported therapy uses communication form to communicate changes with nursing staff, DON, MDS, and floor nurse. This surveyor asked, how do staff know how to care for residents. PTA O reported nurses are expected to review hospital records. PTA O reported staff must review resident hospital records prior to touching resident because many changes can occur in hospital. PTA O reported R1 should not have been left alone on toilet on 1/30/20 prior to fall. PTA O reported after reviewing PT hospital records for R1, indicated min assist(1-25%) with sitting balance and dependant with toileting which meant R1 required total assist during toileting because if R1 shifted weight R1 needed someone to assist with balance. During an interview on 2/27/20 at 10:22 p.m. Assisted Living Director (ALD) K reported being employed by the facility for three years and Assisted Living Director less than one year. ALD K reported management pulls him to work skilled side if needed for staffing needs about two to three times monthly depending on call ins. ALD K reported familiar with R1 because R1 had lived in Assisted Living for several years. ALD K reported he was R1 nurse on the day of 1/30/20 at the time of R1 fall. ALD K reported R1 fell right before lunch about11:30 a.m. and reported first set of neurological assessment completed at 12:15 p.m ALD K reported time on Fall Event was time ALD K entered information in computer. ALD K reported he was at medication cart in the middle of the hall and heard yelling out much louder than normal from R1 room. ALD K reported he entered R1 room and found R1 in the bathroom on the floor laying on right side with palm size blood pooled under right side of head, facing doorway with no staff in room or bathroom. ALD K reported he called for aid R1's CNA L. ALD K reported R1 complained of pain to right side of head that had 1.5 inch laceration above ear. ALD K reported staff know what resident transfer status was by review of the care guide complete by admission nurse. ALD K reported time from fall to start of Fall Event was 30-45 minutes. ALD K reported he did not call R1 Physician by phone but faxed the Physician during regular business hours and notified facility management then started medication pass. ALD K reported R1 did not want to go to hospital and reported R1 family agreed and interventions implemented to stay with R1 in bathroom at all times. ALD K reported to next shift of R1 fall and refusal to go to hospital. ALD K reported management does fall investigation. ALD K reported R1 should not have been left alone in the bathroom prior to fall on 1/30/20. This surveyor asked, if resident needed assist with transfer would you expect staff to remain in eye contact of resident in bathroom? ALD K stated, yes, to prevent falls and provide assistance. During a telephone interview on 2/27/20 at 3:55 p.m. Licensed Practical Nurse (LPN) P reported being employed by the facility for five years and often worked 2nd shift 2pm to 10 pm on 300 hall. LPN P reported R1 had fallen on 1/30/20 prior to LPN P shift at 2:00 p.m. but had refuses to go to the hospital. LPN P reported after speaking with management and R1 family decision made to send R1 to hospital for evaluation about 3:30 p.m LPN P reported R1 returned to the facility about 9:30 p.m. that same night and R1's vitals were obtained at that time. LPN P reported he did not perform vitals or neurological assessment prior to sending R1 to the hospital from 2:00 p.m. through 3:30 p.m. LPN P reported he did not perform neurological assessments after R1 returned from the hospital after a head injury. LPN P reported the facility policy was to perform neurological assessments every 15 minutes for one hour if resident hits head and if normal no need to continue to assess neurological status. Per the Falls/Fall Risk Process Guidelines (MDCH, 2001) residents who have fallen are at risk for delayed consequences which may occur within several days after the fall; occasionally they can occur several weeks later. Acute subdural hematomas develop within 48 hours of injury and have an organized clot. Subacute subdural hematomas develop within 3 days to 2 weeks after a head injury. The chronic subdural hematoma can produce symptoms from about 3 weeks to several months after the injury. The damaged area is filled with fluid rather than an organized clot. (Phipps, W. J., Monahan, F. D., Sands, J. K., Marek, J. F., & Neighbors, M. (2003) Medical-Surgical Nursing Health and Illness Perspectives (7th ed.). St. Louis: Mosby.) Changes in vital signs alone rarely indicate neurologic compromise and any changes should be related to a complete neurologic assessment. Because vital signs are controlled at the medullary level, changes related to neurologic compromise are ominous. (Diseases: Causes and [DIAGNOSES REDACTED].). Pennsylvania: Springhouse). During a telephone interview on 2/28/20 at 9:06 a.m. CNA L reported working at the facility for one year. CNA L reported working with R1 on 1/30/20 from 6:00 a.m. to 2:00 p.m. at the time of R1 unwitnessed fall in the bathroom between 11:30 a.m. and 11:45 a.m. CNA L reported R1 used her call light and reported need to go to the bathroom. CNA L reported ALD K assisted CNA L transfer R1 from the wheelchair to the toilet. CNA L reported ALD K returned to the medication cart in the hall and CNA L left R1 in the bathroom on the toilet alone while CNA L gathered linens from the hall. CNA L reported before CNA L got to the linen room heard someone yell, help from R1 room. CNA L reported ALD K was able to get to R1 first followed by CNA L and observed R1 on the floor in the bathroom with blood in hair. CNA L reported after assessments were completed and three staff assisted R1 off the floor and R1 request to go back to bed. CNA L reported she obtained R1 vitals after fall but R1 fell asleep after returning to bed and remained sleeping until R1 sent to the hospital. CNA L reported R1 went to he hospital after 2:00 p.m. and came back same day before dinner. CNA L reported knows how to care for residents by kardex and was told by nurse two person assist. CNA L reported was told after R1 fall on 1/30/20 by DON B CNA L should have stayed with R1 in the bathroom, and was educated along with rest of staff that resident was not to be left alone in bathroom. During a telephone interview on 2/28/20 at 9:54 a.m. DON B reported would expect staff to monitor neurological status after an unwitnessed fall or head injury every 15 minutes times four and if normal no addition neurological assessment was required according to the facility policy.